How We Did Our Work

Hearings

In the summer and early fall of 2005, the Working Group held hearings
in Crystal City, Virginia; Jackson, Mississippi; Salt Lake City, Utah;
Houston, Texas; Boston, Massachusetts; and Portland, Oregon to learn
about the nation’s health care system. At the first hearings,
health policy experts provided a common foundation on topics including
employer-based and other private insurance, public programs including
Medicare and Medicaid, health care costs, and public and private initiatives
to control costs and expand insurance coverage. At the subsequent
hearings topics included: the uninsured and underserved, health care
quality, geographic variation in health care utilization, health information
technology, rural health issues, mental health, health care disparities,
long-term care, end-of-life care, community-based care, and Oregon’s
experience in public engagement on health care issues.

We also heard of many private and public programs trying to expand
access to care, improve quality, and reduce costs. Some of the programs
we heard about were state and local programs to expand health insurance
coverage; employees and employers working together to expand access
by holding costs down and getting the right care at a good price;
using health care technology to reduce medical errors, monitor patient
care, and choose the most appropriate care for patients; providing
more information to providers and patients for making choices about
health care; encouraging people to use less expensive but equally
effective care such as generic drugs; adjusting payments to doctors,
hospitals, and other health care providers based on the quality of
care they provide; and improving people’s access to care and
insurance coverage through more effective use of current programs
or new programs that will allow small business and self-employed individuals
to obtain coverage.

Many of the programs are new, so we don’t know yet how well
they will work over the long term. And, because these programs were
designed to work in particular places, we don’t know whether
the programs would fit, or work successfully, in other locations or
settings. However, the hearings reinforced our conclusion, as stated
in the Health Report to the American People, that we need
to address the entire health care system, not just specific problems
in cost, quality, or access, no matter how urgent they may seem from
our different perspectives. Ideally, savings gained from improving
efficiency and quality in the system could be used to make other needed
changes. Some of the proposed health care initiatives could help to
keep the amount and type of some health care services we receive the
same, while controlling costs and improving quality. But we also concluded
that none of the initiatives that we reviewed could provide all the
answers to our health care system’s problems. Rather, the hearings
helped lay the groundwork for the search for solutions described in
this report.

A complete list and brief description of the 61 presentations made
by experts at these hearings is found in Appendix E.

Public Dialogue

The Working Group conducted community meetings throughout the United
States to hear from, and begin a dialogue with, the American people.
As stated in the statute, these meetings constitute the primary source
of input that the Working Group has used in developing its preliminary
recommendations. In addition, however, a variety of complementary
forms of input (described below) have been important. These different
types of input were designed to engage a broad segment of the American
public in an informed discussion, using formats that allowed both

free expression of all views, and

sufficient structure to allow the Working Group to characterize
and compare different views in order to reach conclusions based
on the dialogue.

Working Group Community Meetings

The Working Group conducted 31 Community Meetings in 28 states between
January and May 2006 (see Appendix A). These meetings ranged in size
from about 35 to approximately 500 participants. At least one Working
Group Member attended each meeting. Each meeting was organized using
one of a set of formats designed for meetings of different lengths,
but all were based on discussion of the four questions to the American
people posed in the legislation. The discussion guides, as well as
other background materials developed for the meetings (videos, slides,
etc.), were all based on the analysis of issues confronting the American
health care system presented in the Working Group’s publication,
The Health Report to the American People, with some updated
facts and figures. Audience generation for the community meetings
consisted of outreach through both earned and paid media, involvement
of national and local organizations, associations, and other groups,
and the participation of various leaders and government officials
at the local, state and national levels. Professional meeting facilitators
led the meetings.

The basic structure of the meetings involved discussion among participants
sitting in small groups, and a structured process for reporting the
views of the groups. At the 31 Community Meetings, electronic devices
allowed individuals to provide responses to all or some of the same
questions included in the poll posted on the Working Group Internet
site (see Appendix C), and used in other polls and surveys. The responses
to each question were then displayed on a screen, providing immediate
feedback to the participants. As discussed in "The Dialogue"
(below), there was some variation in the wording of the "standard"
questions from meeting to meeting, in response to the preferences
of the groups. The format therefore allowed participants to alter
the discussion when they felt it was important to do so, while providing
enough consistency to allow for comparisons on key issues. Attendees
were also encouraged to provide written comments, and many did so.
Staff of the Working Group also considered these comments in their
review of the meetings.

Additional Meetings

Another important set of discussions took place at the University
town hall meeting sponsored by the Big Ten Conference and the Association
of Schools of Public Health, and hosted by the University of Michigan
on March 22, 2006 (see Appendix D). This virtual town hall provided
a forum for individuals gathered at 22 separate public meetings organized
by the participating universities, along with the webcast of the meeting
from the University of Michigan, as well as people viewing the live
webcast across the country. Interactive technology allowed various
locations to call in with questions and comments, and individuals
submitted their feedback about health care in America through e-mail
to be read to participants during the live event.

Still other meetings organized by individual Working Group Members
and staff in collaboration with community based health, advocacy,
and business groups provided additional insights and opportunities
to hear from people with perspectives that might not have been well
represented at the other community meetings (see below). Some of these
were directly related to issues that were raised in the hearings held
by the Working Group (see Appendix E). These special meetings included
sessions focusing on mental health, health care at the end of life,
chronic illness and disability, a series of meetings in rural areas
of Mississippi, a meeting co-hosted with Native American organizations,
and a meeting organized by a national association representing realtors.

The Working Group also reviewed data from additional meetings that
members as well as other people throughout the country conducted on
their own, using materials developed by the Working Group and made
available to the public in the "Community Meeting Kit" available
on the web site. A listing of meetings that have provided data to
the Working Group is included at the end of this section. Other organizations
have also provided us with information. Among these are: The National
Health Care for the Homeless Council (NHCHC), which conducted a nationwide
outreach effort to gather the input of homeless persons; data from
the responses of 446 homeless persons in 12 cities were provided to
the Working Group.

Other Direct Citizen Input

The Working Group Public Comment Center on its web site solicited
both structured and unstructured comments from the public.

"What’s Important to You" sought responses to
four broad questions about people’s concerns about health
care in America, views on changing the way health care is delivered
or paid for, trade-offs that people would be willing to make to
improve health care, and recommendations that people would make
to improve health care for all Americans. The responses submitted
by over 4,600 people from across the United States were coded into
response categories and analyzed. The full text of close to 2,200
hand written responses was also provided to the Working Group for
review. The United Church of Christ provided us with about 1,500
hand-written responses from people in about 10 percent of its 5,700
churches across the country to the open-ended questions posted on
our Internet site; these are included in our analysis.

Close to 600 people wrote to the Working Group, via the CHCWG
Internet "Share Your Experience" page or in handwritten
letters, to tell us about their own stories. Many of these described
problems obtaining or paying for adequate health insurance or quality
health care; some described very positive experiences with the health
care system.

The Health Care Poll posted on the web site drew over 13,000
responses from January through August 31 (see Appendix C). The Catholic
Health Association (CHA) also provided over 1,000 poll responses
that were submitted directly to CHA’s web site. These are
included in the analysis of poll data; the responses are also presented
in Appendix C. A number of organizations, including Communication
Workers of America (CWA), Starbucks Coffee Company, The National
Health Law Program, the National Assembly on School Based Health
Care, Wheaton Franciscan HealthCare, and the American Nurses Association
also provided information and links to encourage people to provide
input to the Working Group. Many people affiliated with these groups
participated in community meetings and via the Internet. More than
500 members of the CWA responded to the Internet poll (see Appendix
C). Additionally, many of the organizations that conducted their
own meetings sent us paper polls. The Area Agency on Aging in Florida
provided about 50 poll responses from seniors in Florida. Written
input mailed to the Working Group was coded and analyzed using the
same protocols as the electronic data submitted over the Internet.

Analysis of the Data

Methods

The Working Group reviewed summaries of all the sources described
above. The Community Meetings were considered, for analytical purposes,
as case studies. In addition to the data on demographics and the votes
recorded at each meeting, staff reviewed background information on
each location and, in the course of planning each meeting, obtained
a great deal of information on the health care, resources, and policy
issues in each community. Senior staff members who attended the meetings
used a structured format when preparing the meeting reports. The individual
reports, including the data recorded at each meeting, are being made
available to the public on www.citizenshealthcare.gov.
The Working Group compared data across meetings only when it was truly
comparable, that is, questions were asked in the same context during
the meetings, in the same form. (See Appendix B for more information.)

Staff coded and analyzed data from open-ended, on-line polls, and
Interim Recommendation responses using standard statistical software.
The Working Group reviewed summary data, as well as the results of
analyses that reflected possible differences in response patterns
related to demographic differences. The Working Group also reviewed
data from relevant national polls and surveys.

Public Comments

The Interim Recommendations posted on the web site received over
8,000 responses, mostly via the Internet, but also by mail, from June
1 through August 31. These public comments were classified into response
categories and analyzed; comments were also posted on the web site.
Official feedback from advocacy organizations and professional associations
were reviewed by the Working Group members as well as staff, and posted
on the Working Group web site. A summary of the comments and the Working
Group’s response to the comments is presented in Appendix G.

Limitations

People attending the Working Group Community Meetings or providing
input in writing are more likely than others to be especially interested
in health care, either because they, or their family members, have
had concerns about their health care or insurance coverage, or because
they work in the health care field. The people we heard from were,
on average, more likely to be female and in or on the edges of the
Baby Boom generation (age 45-64), and the proportion having bachelor
degrees or advanced graduate degrees was much higher than in the population
as a whole. And, while participation in Community Meetings by minority
group members was fairly close to national percentages, representation
of people who identified themselves as Latino or as African American
among those submitting comments or poll data was lower. The proportion
of people who were not covered by any form of health insurance, and
the proportion receiving benefits through Medicaid, was also lower
than the nation as a whole. Some of these limitations were addressed
by holding meetings specifically designed to reach underrepresented
populations (see above). And, as noted above, analysis of the data
was performed to assess the extent to which demographic factors may
have accounted for some of the findings.

A more serious issue is the inability to ensure that people providing
input represent the full spectrum of views of all Americans, given
that people who are sufficiently interested or motivated to provide
input on health care and policy issues may not be typical of the population
as a whole. The consistency of findings across many communities and
between the poll data obtained through both the Working Group Internet
site and the community meetings provides support for the view that
we have heard from a significant segment of the American people. The
consistency between findings from recent national polls and surveys
provides even stronger support for the findings. However, the meetings,
as well as the www.citizenshealthcare.gov
data were designed to offer information to help frame discussion and
responses to questions, whereas national polls and surveys generally
do not serve this purpose. Therefore, the responses we have analyzed
are not exactly comparable to other national poll data, even when
the same, or very similar, questions are asked. Consequently, we do
not claim that we know, with great certainty, the values and preferences
of all Americans. Rather, we are basing our recommendations on a careful
assessment of input from as many sources as feasible, from tens of
thousands of people from all across the United States, taking into
account the gaps or biases that may be reflected in the data to the
best of our ability.

The Alliance for Human Services, The Human Services Coalition,
Florida CHAIN, Miami-Dade County Health Department, Health Foundation
of South Florida

August 22, 2006

Self-Initiated Meetings (table)

Crossville, TN

The Learning Community

January-March, 2006

Galena, IL

League of Women Voters

February 23, 2006

Starkville, MS

MSU Extension

March 21, 2006*

Verona, MS

MSU Extension

March 27, 2006*

Wesson, MS

MSU Extension

March 29, 2006*

Hattiesburg, MS

MSU Extension

March 30, 2006*

Clarksdale, MS

MSU Extension

April 11, 2006*

Palm Beach Gardens, FL

Human Resource Association of Palm Beach County

April 11, 2006

Greenville, MS

MSU Extension

April 18, 2006*

Newton, MS

MSU Extension

April 20, 2006*

Cloverdale, CA

United Church of Cloverdale

April 23, 2006

Eau Claire, WI

Chippewa Valley Technical College

April 29, 2006

Seattle, WA

Association of Advanced Practice Psychiatric Nursing

April 29, 2006

Alpena, MI

League of Women Voters

May 1, 2006

Galveston, TX

Center to Eliminate Health Disparities, University of Texas
Medical Branch

May 1-3, 2006

Boulder, CO

Individuals

May 3, 2006

McKeesport, PA

Mon Valley Unemployed Committee

May 11, 2006

Muncie, IN

BMH Foundation and Partners for Community Impact

June 2, 2006

Birmingham, AL

Greater Birmingham PDA/DFA, UFCW Local 1657

June 22, 2006

Corvallis, OR

Mid Valley Health Care Advocates

July 20, 2006

Birmingham, AL

Birmingham Friends Meeting

July 16, 2006

Jackson, MS

MSU Extension

August 22, 2006*

Hattiesburg, MS

MSU Extension

August 23, 2006*

Greenville, MS

MSU Extension

August 24, 2006*

Cleveland, OH

North East Ohio Voices for Health Care

August 24, 2006

Columbus, IN

Columbus Regional Hospital Foundation (2)

August 29, 2006

* Held under the auspices of the Mississippi State University Extension
Service.

Community Meetings on Interim Recommendations (table)

San Jose, CA
eBay/PayPal

July 20, 2006

Oklahoma City, OK

August 1, 2006

Milwaukee, WI

August 12, 2006

Locations of Community Meetings Across the United States
(map)

The Dialogue

This chapter highlights public input on the four questions Congress
specified that the Citizens’ Health Care Working Group ask the
American people. The Working Group has reviewed all input it has received
from community and other meetings, by Internet, by mail, in person,
or by phone. Particular emphasis in this section has been given to
information gathered in community meetings held throughout the nation,
which Congress directed the Working Group to conduct before preparing
its Interim Recommendations. Other survey data sources are discussed
throughout this section, and they will also be highlighted in the
Final Recommendations to Congress.

This chapter follows the organization of the "typical"
meeting, which always began with a discussion of participants’
underlying values. The 31 community meetings varied slightly from
site to site, reflecting differences in the participants’ interests
and preferences. While the general structure of the meetings was similar,
it evolved over time as the Working Group attempted to find more effective
ways to gather the desired information. Meetings varied in length,
with most meetings either three or four hours long, although some
were shorter and a few longer. At all these meetings, discussions
centered on the four legislatively mandated questions:

I. What health care benefits and services should be provided?

II. How does the American public want health care delivered?

III. How should health care coverage be financed?

IV. What trade-offs are the American public willing to
make in either benefits or financing to ensure access to affordable,
high-quality health care coverage and services?

Summary of Findings

The following common themes emerged from the community meetings and
other sources of information collected from the American public by
the Working Group:

Values

Underlying the discussion of the four legislative questions is
the belief by virtually everyone in attendance at each community
meeting that the health care system has at least some serious problems.

Over 90 percent of participants at community meetings and respondents
to the Working Group’s poll believed that it should be public
policy that all Americans have affordable coverage.

I. What health care benefits and services should be provided?

A clear majority of participants preferred that all
Americans receive health care coverage for a defined level of services.

People at the community meetings frequently expressed strong
support for increased focus on wellness and prevention services
as part of "basic" coverage, rather than focusing only
on treating sickness.

Participants at meetings continually emphasized the importance
of a strong education component in health care and the management
of health.

Individuals voiced support for a fairly comprehensive basic benefit
design.

Although many participants recognized the need to do more to
ensure that the health care provided is appropriate and delivered
efficiently, they were also concerned about arbitrary limits on
coverage and were not comfortable with bare-bones benefit packages.

Despite the reluctance of many to limit benefits, participants
at meetings supported limiting coverage to services that have proven
medical effectiveness.

Participants expressed some level of support for the idea that
some people could pay for additional services outside the basic
benefit package.

People wanted consumers to play an important role in deciding
what should go into a basic benefit package.

Participants in some meeting sites discussed a potential role
for a local board or other quasi-governmental entity in defining
the basic level of services.

Participants expressed the desire to be involved in the management
of their own health care and were willing to accept some responsibility
for their medical decision-making.

II. How does the American public want health care delivered?

At the community meetings, individuals asked for a delivery system
that is secure, transparent, easy to navigate, and treats the "whole
person."

Affordability of care is a primary concern among participants.

Participants were troubled that many people did not have access
to the health care they need.

Many participants cited complexity of the system as a contributing
factor to the problems with the health care system.

Linked to confusion about the health care system was the lack
of useful information to help individuals navigate the health care
system.

Participants mentioned that they or others were not always treated
with respect or dignity.

Participants told the Working Group that they want to feel secure
knowing that when they or their families need care, they can get
it without becoming impoverished.

Participants wanted all Americans to be able to get the right
health care, at the right time, in a respectful manner.

Participants noted that being able to choose and maintain a stable,
long-term relationship with a personal health care provider was
critical.

III. How should health care coverage be financed?

Although the results differed across meeting sites, a majority
of participants (ranging from 55 percent to 88 percent in the community
meetings) believed that everyone should be required to enroll in
either private or public "basic" health care coverage.

In almost every community meeting, a majority of participants
supported the notion that some individuals should be responsible
for paying more for health care than others. The most commonly mentioned
criterion for paying more was income, but varying payment by income
was supported by the majority of participants in fewer than half
of the meetings where this question was discussed.

Views about employer-based coverage did not generally reflect
a deep distrust of employers, but instead were intertwined with
broader concepts of health reform.

At most meetings, participants stressed the importance of preventive
care to reduce health care costs.

Participants at most meetings believed that individuals have
a responsibility to manage their own care and use of services.

In many meetings, participants mentioned that individuals have
a social responsibility to pay a fair share for health care.

Participants frequently stated that the problems of high costs
rest with "price setters"—namely, prescription drug
companies, insurers, and for-profit providers.

A commonly expressed view was that a simpler system would result
in lower administrative costs.

Some support exists for investment by providers and the private
sector in health information technology to increase system efficiency.

Participants expressed general support for individuals playing
their part in controlling utilization and costs.

Individuals would like information about how to use health care
better and more effectively.

At some meetings, participants supported providing incentives
to patients to engage in healthy behaviors.

Participants expressed preferences for using medical evidence
to decide which services are covered and provided.

There was general support for controlling prescription drug costs
by limiting direct-to-consumer advertising of prescription drugs
and using more generic drugs, when medically appropriate.

In almost all community meetings, participants expressed the
belief that changing the culture from sick care to well care—namely,
by focusing on prevention, wellness, and education (in general,
and health education in particular)—will reduce health care
costs.

A commonly expressed view was that better use of advanced practice
nurses and other non-physicians could save money and improve quality.

Participants believed that investing in public health would pay
dividends in terms of reducing health care costs.

Support for limits on malpractice was expressed at some community
meetings.

IV. What trade-offs are the American public willing to make
in either benefits or financing to ensure access to affordable, high-quality
health care coverage and services?

In most meetings as well as on the Working Group poll, a majority
of participants expressed a willingness to pay more to ensure that
everyone has access to affordable, high-quality health care. Overall,
about one in three (28.6 percent of poll participants) said they
were willing to pay $300 or more per year.

When asked to rank or choose among competing priorities for public
spending on health, individuals—with few exceptions—were
most likely to rank "Guaranteeing that all Americans have
health coverage/insurance" as the highest priority.

When asked to evaluate different proposals for ensuring access
to affordable, high-quality health care coverage and services for
all Americans, individuals at all but four meetings ranked "Create
a national health insurance program, financed by taxpayers, in which
all Americans would get their insurance" the highest.
Three other options generally ranked in the top four choices at
the community meeting locations: "Expand neighborhood health
clinics"; "Open up enrollment in national federal
programs like Medicare or the federal employees’ health benefits
program"; and "Require that all Americans enroll
in basic health care coverage, either private or public."

Detailed Description of Findings

Values

Before focusing on the four legislative questions, all meetings began
with a discussion of individuals’ underlying values and perceptions
that generally centered on three questions:

When asked how they would describe the U.S. health care system
today, 97 percent of attendees across all community meetings selected
"It is in a state of crisis" (64 percent) or "It
has major problems" (33 percent). In each of the 31 community
meetings, at least 88 percent selected one of these options. Overall,
only two percent said "It has minor problems,"
and one percent either said "It does not have any problems"
or had no opinion. Underlying the discussion of the four legislative
questions is the belief by virtually everyone in attendance at each
community meeting that the health care system has at least some serious
problems. This same concern has also surfaced in national
polls. A January 2006 New York Times/CBS poll found that 90 percent
of respondents said that our health care system needs fundamental
changes or to be completely rebuilt (56 percent and 34 percent, respectively).1
This finding has been fairly consistent over the past 15 years. However,
the Employee Benefit Research Institute’s annual Health Confidencet
Survey has found from 1998 to 2004 the percent of respondents rating
our health care system as poor has doubled from 15 percent to 30 percent.
2

When meeting participants at all meetings were asked, "Should
it be public policy that all Americans have affordable health care
coverage?", 94 percent overall said "yes." Similarly,
in the Working Group’s poll, 92 percent either strongly agreed
(79 percent) or agreed (13 percent) with this statement. Over
90 percent of participants at community meetings and respondents to
the Working Group’s poll believed that it should be public policy
that all Americans have affordable coverage. As stated by
participants in the Orlando community meeting, "Health care is
a right and not a privilege." Seattle, Denver, and Philadelphia
meeting participants, among other locations, desired "cradle
to grave" access to health care.

At many of the community meetings, participants were asked what
they believed was the most important reason to have health insurance.
Although the results varied by meeting site, individuals were more
likely to choose the response "To protect against high costs"
than they were to choose the response, "To pay for everyday medical
expenses."

Figure 1 illustrates how participants’ responses varied across
community meeting sites and the Working Group poll.

Note: This question was not asked in Los Angeles, Albuquerque, Hartford,
Las Vegas, San Antonio, Fargo, Lexington, Little Rock, or Sioux Falls.
Eugene and Baton Rouge were the meeting sites where "Pay for everyday
medical expenses" ranked as the lowest among the cities where the
question was asked, while Philadelphia and Providence were the meeting
sites where that option ranked as the highest. The meeting average reflects
a weighted average of all meetings where this question was asked.

What health care benefits and services
should be provided?

Some common themes have emerged from the community meetings regarding
what health care benefits and services should be provided. In the
community meetings, discussion of this question generally revolved
around three core questions.

The first of these questions is discussed below:

"Health care coverage can be organized in different
ways. Two different models are: (1) Providing coverage for particular
groups of people (e.g., employees, elderly, low-income) as is the
case now; (2) Providing a defined level of services for everyone (either
by expanding the current system or creating a new system). Which of
the following most accurately reflects your views?"

In response to this question, a strong preference emerged:

A clear majority of participants preferred that all
Americans receive health care coverage for a defined level of services.
In response to the question, the vast majority (between 68 percent
and 98 percent) of participants at all community meetings have said
that we should provide a defined level of services for everyone.
The highest level of support for a defined set of services was in
the community meetings that were held in Philadelphia and New York,
and the lowest in the Baton Rouge meeting (See Figure 2).

Figure 2:

Which statement best describes your views on how health care coverage
should be organized?

In the Working Group poll, 84 percent of participants answered the
question this way. These findings are also consistent with the results
of other national polls asking similar questions. In surveys conducted
by other organizations, a clear majority have expressed the opinion
that all Americans should have health insurance. For example, a Wall
Street Journal poll regarding public support for a range of health
practices in September 2005 found that 75 percent of U.S. adults somewhat
favored (23 percent) or strongly favored (52 percent) universal health
insurance.3 More recently, a New York Times/CBS poll
conducted in January 2006 found that 62 percent said that they think
the federal government should guarantee health insurance for Americans;
31 percent said this was not the responsibility of the federal government,
and 7 percent said they do not know. 4

Discussions at community meetings teased out variations in how people
conceptualize health coverage. For example, some participants indicated
that it was hard to make a choice between the answers without knowing
who was providing the coverage, or what would be covered. Many tended
to view access to health care as a basic right, and they conveyed
a willingness to contribute to the success of a system that would
facilitate health care for all.

In the Baton Rouge community meeting, where the smallest percentage
of people opted for providing a defined level of services for everyone,
participants still concluded that a defined level of services for
everyone was "more fair and equitable" in the face of
the current system that was "failing."

In the Detroit community meeting, some participants worried
that the issue of discrimination needed to be addressed, regardless
of the system design. Just like the current system of providing
coverage for particular groups of people (such as Medicare or Medicaid
for elderly, disabled persons or low-income populations, or group
coverage organized through employment), a system providing a basic
level of care for everyone ran the risk of not providing sufficient
levels of care for all. Participants expressed concern that any
system reform must avoid creating different levels of care for different
subsets of the population.

At the two largest community meetings in Los Angeles and Cincinnati,
fewer than 10 percent of participants favored the current system
that provides coverage according to a person’s affiliation
with a particular group. These participants, like those at the other
meetings, cited problems with the current system, including:

It excludes the unemployed and others who are not part
of a particular group

The system is high cost, complex, and not uniform across
groups

Mobility and flexibility are a problem.

About 90 percent of participants supported the option of providing
a defined level of benefits for everyone, rather than the current
system of coverage for certain groups. The virtues of implementing
a system of coverage for all that were mentioned included:

Reduced overall and administrative costs

Decreased hospitalization and emergency room use

Access for all

Covered prevention and immunization, and

Improved level of national health care.

However, participants also expressed potential concerns about such
a system, such as: What is the defined level of services? Who will
be denied access to care if costs are too high, and who will make
these decisions? Who will pay?

At all locations, participants emphasized the importance of
involving consumers in the development of a basic benefit package.
Because consumers can articulate what services are necessary at
various stages of life, their participation in the development of
the plan could help contain costs. In the Phoenix community meeting,
for example, participants wanted a basic plan that would vary based
on age and gender, and that could be added to if desired. Participants
at most meetings recognized that the current system does work for
some, and allows for a richer benefit than might be available otherwise,
but that it does not work for everyone. They expressed a desire
to build upon the current system, changing it into something that
is more inclusive and provides a level of care for all Americans.
Everyone would contribute to this system based on their ability
to pay. However, for those people who are unable to afford the cost,
government subsidies should be provided to allow access to a basic
package.

In the San Antonio community meeting, participants expressed
interest in an approach that would provide a basic level of care
for everyone combined with personal responsibility.

In a number of community meetings, including Lexington, Eugene,
Sioux Falls, and Cincinnati, participants commented that the United
States should learn from other countries that have covered all or
most of their citizens.

The second structured question delved into how to define the specific
level of benefits:

"It would be difficult to define a level of services
for everyone. A health plan that many people view as ‘typical’
now covers these types of benefits, many of which are subject to co-payments
and deductibles: preventive care, physicians’ care, chiropractic
care, maternity care, prescription drugs, hospital/facility care, physical,
occupational, and speech therapy, and mental health and substance abuse.
How would a basic package compare to this ‘typical’ plan?
Are there benefits that you would add or would take out?"

Although the discussion differed by meeting location, some common
themes emerged:

People at the community meetings frequently expressed strong
support for increased focus on wellness and prevention services as
part of "basic" coverage, rather than focusing only on treating
sickness. According to participants at meetings throughout
the country, individuals have a responsibility to be good stewards
of their health and health care resources (preventive care/screenings/use
of services). They also viewed an emphasis on wellness and prevention
services as a way to reduce health care costs, as discussed in the
Financing section. According to these participants, disease management
should also be a part of the focus. In the Working Group poll, over
90 percent of respondents indicated that annual physicals and preventive
care should be part of a "basic" or "essential"
benefits package, a level of support that was similar to that for
hospital stays, prescription drugs, and lab tests.

Participants at meetings continually emphasized the importance
of a strong education component in health care and the management
of health. To be good stewards of their health, individuals
need to be educated about wellness and prevention. People thought
information about how to use health care better and more effectively
was important, but not information on cost. Broader issues of general
education also came up in some meetings. Participants talked about
the importance of beginning early, in grade school, to focus on basic
skills that are prerequisites to literacy and health literacy. Fargo
meeting participants expressed a preference for "school-based
health promotion programs" for those in kindergarten through
grade 12.

Individuals voiced support for a fairly comprehensive basic
benefit design. Benefits that a number of participants in
meetings throughout the country viewed as important components of
a basic benefit package included—but were not limited to—dental
care, vision, hearing, care by non-physician providers such as nurse
practitioners, long-term care, mental health, and hospice care. Some
meeting participants also desired coverage of complementary and alternative
medicine (for example, acupuncture).

Although many participants recognized the need to do more
to ensure that the health care provided is appropriate and delivered
efficiently, they were also concerned about arbitrary limits on coverage
and were not comfortable with bare-bones benefit packages.
A participant in the Eugene community meeting made the point, "There’s
a need for definition because we can’t afford it all."
Still, when pressed to make decisions about what services to drop
from basic coverage, many respondents told the Working Group "None,"
which was the most popular response in some locations.

"All people should have the same coverage
that the President, Vice President, and Congress have…"
(Phoenix meeting)

"We agree that there should
be a basic level of services for everyone- everyone has a right
to that care. But our concern is that neither of those--what we
have now, or a basic plan for everyone-- will work until it’s
a consumer-driven choice and not a corporate solution that values
profits above everything else. The consumer should be driving the
choices, not like the way the culture is now. There should be more
of a balance."
(Charlotte meeting)
"Every citizen has a basic right to have basic health care,
and it can’t be based on the type of job they have."
(Salt Lake City meeting)

Despite the reluctance of many to limit benefits, participants
at meetings supported limiting coverage to services to those that
have proven medical effectiveness. They expressed a certain
level of comfort with decisions that could affect utilization, if
they were based on medical evidence. Just over half of the Working
Group poll respondents agreed (36 percent) or strongly agreed (14
percent) that health plans or insurers should not pay for high-cost
medical technologies or treatments that have not been proven to be
safe and medically effective, and nearly a quarter were neutral on
the subject; responses in the March University town hall meeting were
similar (see text box below), with 58 percent agreeing (36 percent)
or strongly agreeing (22 percent).

University Virtual Town Hall Meeting:
"A National Conversation on Health Care"

On March 22, 2006, 22 universities participated
in a simultaneous discussion on health care. Sponsored by the Big
Ten Conference and the Association of Schools of Public Health,
and hosted by the University of Michigan, this virtual town hall
meeting provided a forum for individuals across the country to voice
their opinions on health care.

Broadcast via satellite from the University of Michigan, individuals
participated in this event either by gathering at various university
sites, or by logging onto the forum through the Internet. Interactive
technology allowed various locations to call in with questions and
comments, and individuals submitted their feedback through e-mail
to be read during the live event. The 21 simultaneous meetings held
in addition to the host meeting were organized by their respective
university communities, and followed the same format. Participants
at these meetings received the standard Community Meeting Discussion
Guide and a Health Care Poll, specific to this event, which included
the majority of questions asked on the Working Group’s own
Internet poll (as well as in many of the Working Group Community
Meetings). The separate meetings also had access to a local faculty
expert who assisted in sending comments and questions to the national
coordinator at the University of Michigan. After the event, the
completed Health Care Polls were coded (772 from 22 of the webcast
sites) and entered into a data set that was made available to the
Working Group for analysis (See Appendix D for a complete summary
of the results). Participating schools were:

Boston University
Drexel University
Emory University
George Washington University
Indiana University
Johns Hopkins University
Louisiana State University
Michigan State University
Northwestern University
Ohio State University
Penn State University
Purdue University
Tulane University
University at Albany
University of Arkansas
University of Illinois
University of Iowa
University of Louisville
University of Michigan
University of Minnesota
University of South Carolina
University of Wisconsin

Participants expressed some level of support for the idea
that some people could pay for additional services outside the basic
benefit package. For example, in Kansas City, participants
favored allowing individuals to purchase additional coverage of chiropractic
care or fertility treatments. Charlotte participants were willing
to pay more for an "a la carte" plan that would allow people
to add services to the basic plan, which could vary by life phases
and would be most cost effective for each age group. At virtually
every meeting, attendees expressed concern about coverage for "futile"
care at the end of life.

Results of the Working Group poll question about the importance of
including each of 23 specific benefits can be found in Appendix C (Question
4 of the Working Group poll).

The next question in this section of the community meetings asked participants
for their views on who should decide which benefits would go into the
basic benefit package:

"How much input should each of the following groups
have in deciding what is in a basic benefit package (federal government,
state and/or local government, medical professionals, insurance companies,
employers, consumers)?"

Some common themes emerged in response to this question:

People wanted consumers to play an important role in deciding
what should go into a basic benefit package. In meetings
throughout the country, the majority of participants consistently
answered that a combination of consumers, medical professionals, federal
government, state and local governments—generally in that order—should
be responsible for having input into these decisions. Some participants
indicated that employers and insurance companies should also play
a role, but one that is more limited.

In the majority of meetings, participants were asked, "On
a scale of 1 (no input) to 10 (exclusive input), how much input should
each of the following have in deciding what is in a basic benefit package?"
When participants were asked the question in this way, the highest rating
was always for input from consumers, and it was always followed
by "medical professionals."

"Some new entity or process needs to
be created that includes all the relevant stakeholders, the foremost
of which would be the consumer."

"[There should be] a ‘quasi-governmental’ entity
representing all groups, including us, the people."

"One way to organize this would be to create an entity very
much like the Federal Reserve Board with appointed individuals who
are professionals in their field and whose activities are generally
public so it has to come under the federal government but wouldn’t
be the government as we generally think of it."
(Orlando meeting)

Responses to this question are illustrated in Figure 3. In some meetings
and on the Working Group poll, individuals were asked which party or
parties they would prefer to make the decision regarding what services
are covered in the basic health insurance plan. At least 60 percent
of Working Group poll respondents and participants in the half dozen
community meetings in which the question was asked this way chose the
"some combination" option (of consumers, employers, government,
insurance companies, and medical providers; the question did not identify
which specific combination people preferred).

In the Sioux Falls meeting, participants were also asked to rate the
"degree of involvement" government, medical professionals,
insurance companies, employers, and citizens should each have in determining
what is included in a basic health care package using the scale: major
role, minor role, and no role. Consistent with other findings, 88 percent
of participants voted that citizens should have a "major role,"
and 73 percent indicated that medical professionals should have a "major
role." Participants generally believed that government (72 percent)
and employers (64 percent) should play a "minor role;" insurance
companies received a mixed response, with 55 percent saying they should
play a "minor role" and 42 percent saying they should play
"no role."

Figure 3 (table):

On a scale of 1 (no input) to 10 (exclusive input), how much
input should each of the following have in deciding what is in a basic
benefit package?

Location

Federal Government

State/Local Government

Medical Professionals

Insurance Companies

Employers

Consumers

Jackson

3.6

3.0

5.7

1.8

3.6

7.8

Seattle

4.3

4.0

5.9

1.6

2.3

7.3

Denver

4.2

4.0

6.4

2.5

3.8

6.8

Providence

4.1

3.8

6.8

2.3

2.8

8.0

Miami

5.0

4.5

5.5

2.3

3.0

6.9

Indianapolis

4.9

3.9

6.1

2.2

3.3

7.6

Detroit

3.5

3.7

6.8

1.4

2.4

7.6

Phoenix

3.9

3.7

5.2

2.0

3.4

7.7

Des Moines

5.0

4.7

5.4

2.2

2.6

6.7

Philadelphia

4.4

4.4

6.0

1.5

3.1

6.7

Sacramento

3.8

3.8

6.4

2.5

2.9

7.4

Billings

5.1

4.7

6.0

2.4

4.0

6.3

New York

5.2

4.1

6.7

1.4

2.1

7.7

Tucson

3.9

3.4

6.2

2.6

3.2

6.6

Salt Lake City

4.6

4.7

4.9

2.6

3.1

6.8

Average

4.4

4.0

6.0

2.1

3.0

7.2

Participants in some meeting sites discussed a potential
role for a local board or other quasi-governmental entity in defining
the basic level of services. For example, participants in
the Memphis community meeting strongly supported the concept of defining
the basic level of service using a "grass roots" method
through regional or state boards. In these discussions, participants
emphasized the need for a publicly accountable body.

Participants expressed the desire to be involved in the
management of their own health care and were willing to accept some
responsibility for their medical decision-making. Meeting
participants felt that consumers played an important role in decision-making.
This opinion was expressed both by individuals who sought a larger
role for government and those who preferred that government have a
limited role.

Mental Health Meeting

At its Boston meeting in August 2005, the Citizens’
Health Care Working Group heard from a panel made up of the Director
of Mental Health Services for Massachusetts, a representative from
a managed behavioral health care plan and an advocate for the mentally
ill. As members of the Working Group attended community meetings,
they heard that access to mental health services was a significant
issue to many participants. In order to delve more deeply into issues
related to mental health, the Working Group sponsored a meeting
focused on this topic in Atlanta, Georgia on May 22, 2006, at Skyland
Trail, a mental health facility which offers long- and short-term
residential care and community-based therapy, with the National
Mental Health Association of Georgia as a host.

The participants at this meeting were knowledgeable about mental
health. They included providers and consumers of mental health services,
family members and advocates for the mentally ill and other health
care providers. The meeting format was a mix of questions used at
other community meetings and questions specific to mental health.

Attendees believed that the value most fundamental to a health care
system "that works for all Americans" is universal access,
with health care as a right. Other important values are affordability
and equal quality of care for all. In considering what was most
important to the delivery of mental health care services, universal
access was also the most important value, accompanied by integration
of mental health into primary health care, parity for mental health
care and eliminating the stigma attached to mental health.

The issue participants believed most important to address in getting
mental health care services is the lack of parity in insurance treatment
of mental illness. Other problems that are priorities for action
include the need for more funding for mental health services, the
stigma associated with mental health conditions, continuity of care
and the need for education to help people "know what is wrong
and where to go for help." The inappropriate criminalization
of mental health behaviors was also identified as a problem. When
asked about the delivery of mental health services within the overall
health care system, a majority of attendees embraced this vision
which was developed by one table of participants:

A comprehensive delivery system
through primary care to include addictive disease, mental illness
and all other physical illnesses with:

Education for all providers on mental illness

A robust referral system. and

Access to services driven by consumer choice.

Ultimately, attendees wanted a system of "any
door" access to services where dollars follow the consumer,
and there is a focus on wellness recovery and resiliency.

How does the American public want health
care delivered?

In general, community meeting discussions of how the public wants
health care delivered have been structured around two central questions.
The first is discussed below:

"What kinds of difficulties have you had in getting
access to health care services?"

Individuals at the community meetings discussed a number of problems
they or their family members have had in getting access to health
care services. Some common themes emerged that are summarized below.

"When you change insurance, you should
be able to keep your doctor."

"Primary
care doctor—I like that relationship and I don’t want
to see that go away."
(Charlotte meeting)

"It is an accident of
history that medical insurance is attached to the place of employment,
only to be lost or changed if jobs change or are lost."
(Comments submitted to CHCWG Internet "What’s Important
to You?")

At the community meetings, individuals asked for a delivery
system that is secure, transparent, easy to navigate, and treats
the "whole person." Having a continuing relationship with
a personal physician is just one component of a stable system, according
to the participants. Confidentiality of medical records was mentioned
as another important component of a good health care system. Individuals
expressed a desire for a system that is holistic, treating the whole
person rather than just treating "a bundle of symptoms,"
as described in the Denver community meeting.

Affordability of care is a primary concern among participants.
At meetings throughout the country, individuals discussed how costs
had prevented them or others from getting needed care. Costs of
care generally referred to their (or their family’s) costs,
including co-payments, deductibles, and health insurance premiums,
rather than system-wide costs. Participants in different cities
indicated that the high costs of prescription drugs were a particular
concern. Participants in the Salt Lake City meeting discussed how
"people are being priced out."

"More than anything at our table
we have been talking about the cost of the health care –
cost is keeping people from getting the care."
(Phoenix meeting)

"We want health care
delivered equitably at the community level by people we trust."
(Memphis meeting)

"We have rural areas here
in Indiana where you can’t even get a paramedic."

"We have lost time-intensive care. Providers right now don’t
have time to spend with us! You only get two minutes with your
doctor."
(Indianapolis meeting)

National polls have shown that the cost of health care overshadows
concerns about quality. In fact, almost three-quarters (73 percent)
of those surveyed in a 2005 Gallup Poll said they were greatly concerned
about cost; less than half rated other items such as medical errors
or avoidable complications, privacy of health information, or availability
and access to services as great concerns.5 The EBRI 2004
Health Confidence Survey found that 34 percent of respondents were
not at all confident (23 percent) or not too confident (11 percent)
in their ability to afford health care today. The figure rose to 44
percent (25 percent not at all confident and 19 percent not too confident)
when the respondents were asked about being able to afford care ten
years out.6 For the last twenty years, a variety of survey
findings consistently showed that approximately one in four Americans
reported problems paying medical bills in the previous year.7
Surveys have continued to describe that burden Americans are feeling
as it relates to the costs of medical care. According to a 2006 CBS/New
York Times Poll, 61 percent of adults said they were concerned a lot
about the health care costs they are facing now or will face in the
future,8 A Pew Center for the People and the Press Survey
found that 54 percent of U.S. adults reported that the costs of paying
for a major illness was a major problem and 38 percent said even routine
care was a major problem. Moreover, 70 percent of respondents said
that the government spends too little on health care, while 65 percent
thought that the average American spends too much. 9

"Culturally competent care-funding
to encourage more minority physicians and providers. If I want
an African American dermatologist, I have to search high and low."
(Indianapolis meeting)

"You can’t
get through this system without luck, a relationship, money, and
perseverance."
(Salt Lake City Meeting)

"Care should be
delivered at the most local level possible."
(New York Meeting)

Participants were troubled that many people did not have access
to the health care they need. Access to care includes access to
both facilities and health care providers, including specialists.
Participants in community meetings nationwide highlighted problems
with access to health care in rural areas, including lack of transportation
to providers or facilities located far away. The lack of public
transportation was brought up as an issue not only for rural areas,
but for urban areas as well. Others described problems finding an
accessible provider who was willing to accept their insurance, particularly
Medicaid. Providers and facilities tend to be concentrated in suburbs
and more populated areas. For example, in the Phoenix community
meeting, individuals noted that most providers and specialists were
concentrated in the Phoenix area, and it was difficult to access
care in other areas of the state. According to a national Wall Street
Journal/Harris Interactive survey 56 percent of adults agree that
people who are unemployed and poor should be able to get the same
amount and quality of medical services as people who have good jobs
and are paying substantial taxes. 10

Consolidated Tribal Health Project, Redwood Valley, California

"I don’t have money to get
my kids milk and you want me to take them to the dentist?"

"Society preaches prevention—but a doctor isn’t
going to see this young lady’s kids for preventive care.
She might get in at a walk-in clinic, but what’s the quality
of care? Is the waiting room safe? Is the provider credentialed?
Are they culturally sensitive to your needs? We get referred to
the outside world where they assume you can read and write and
just have you signing forms and don’t take the time to explain
it to you."

Native Americans (both tribal and non-tribal members) met in Redwood
Valley on April 20, 2006, at the Consolidated Tribal Health Project
to provide an open, honest, and often emotional insight into the
barriers they face in accessing even basic primary medical, mental
and dental health care. Participants expressed their desire for
everyone to have access to health care, both in terms of geographic
distance and ability to access providers.

They felt that "health care is not a privilege, it’s
a right and we don’t receive that right…not only as
Native Americans, but as rural citizens." Individuals addressed
the issue of access as a multi-pronged problem. One woman said,
"When they can afford to purchase gasoline, their tires are
in good shape, and they aren’t in too much pain, they can
make the long drive for care." If the primary care reveals
a need for specialty services, they face an even greater hurdle.

Individuals talked about how they valued culturally competent
care with providers who took the time to explain medical terminology
and did not assume literacy. One person noted that "[health]
professional people are so professional that they don’t
know how to relate to us nobodies. They don’t know how to
tell us the simple things." Participants at this meeting
emphasized the importance of the government recognizing its duty
to the Native American population and honoring the trust relationship
that is established in law.

Mississippi Listening Sessions

Eleven listening sessions organized by faculty
of the Mississippi State University Extension Service were conducted
between March 21, 2006 and April 20, 2006. These sessions were
held across the rural areas of the state and included a diverse
mix of geographies and cultures. Altogether, 138 people participated
in the sessions. The majority of participants were college graduates,
many with post-graduate education, and most had some form of health
coverage. Many of the participants were health care providers
or administrators, or business people actively involved in their
communities, and most were knowledgeable about the problems facing
low-income and underserved rural Mississippi communities. A major
thought expressed across the rural sessions was that many problems
with the health care system in rural areas are distinct from those
found in more urbanized areas. Lack of physicians and other health
care professionals, distances to services, transportation issues,
high cost, and lack of insurance were strongly recurring themes
across the state.

Across the sessions, values regarding affordability and quality
of care ranked highest among participants. Accessibility ranked
third in urgency, but the total number of specific issues related
to this concept dominated the discussion. Choice of care rounded
out the list of values articulated at the sessions.

Those observing the sessions noted that there were marked differences
in the views expressed in the meetings, reflecting at least in
part, differences in culture, but also the recent major devastation
caused by Hurricane Katrina. Participants from the state’s
southern regions, hardest hit by the storm, talked about problems
they still face getting health care. Doctors left and patient
records were destroyed or disappeared. And when some doctors attempt
to return, they are finding that their patient base is scattered
and possibly gone for good. Concerns were also expressed in the
other regions of the state focused on the influx of Katrina and
Rita evacuees (many of these evacuees are either uninsured or
are covered by Medicaid) and the accessibility barriers that these
people faced. Other storm concerns involved the lack of generators
for respirators and difficulty accessing medication. One person
who became the guardian after the storm of a 3-year old child
who is covered by Medicaid seemed overwhelmed: "I don’t
know what to do or how to access the system." Another left
the same session highly distressed contending that, in light of
this system’s inability to quickly respond to Katrina, we
had no business focusing on health care issues that will take
years to address, and that we should instead focus our attention
on the possibility of other natural disasters, a potential pandemic,
or a bioterrorist attack.

In other sessions, people talked about more pervasive problems,
including delays in the ability to schedule an appointment, and
physicians who are unwilling to accept Medicaid or Medicare patients.
Problems related to communicating with the system led one participant
to advocate the establishment of patient navigators. One session
in Hattiesburg focused on small businesses’ and independent
contractors’ inability to secure reasonable group rates;
it was mentioned that 28 percent of National Association of Realtors
members have no health care coverage.

Most participants (78 percent) agreed with the statement, "It
should be public policy that all Americans have affordable health
care." Compared to other meetings, however, participants
expressed a stronger interest in focusing on personal responsibility
(including taking advantage of educational opportunities) to improve
health care and control health care costs, investing in public
health infrastructure, and expanding safety net programs in order
to ensure access to care. There was also a greater emphasis on
expanding existing public programs and bolstering the employer-based
health care system to address gaps in coverage, rather than initiating
new programs or making fundamental changes to the health care
system. The most resounding dialogue the group facilitators recalled
at all the sessions focused on the availability of health care
services.

Many participants cited complexity of the system as a
contributing factor to the problems with the health care system.
A number of issues related to complexity were discussed. Some participants
noted that a lack of transparency in insurance coverage and reimbursement
policies contributed to the problems. In the Memphis community meeting,
the discussion of the complexity of the insurance system emphasized
the problems created by multiple payers. Related to the concept
of multiple payers, participants in the Denver community meeting
discussed how the "labyrinthine scheme of Medicare and Medicaid"
sets up a system especially hard to navigate by or on behalf of
elderly patients. In the Providence, Philadelphia, and Sacramento
community meetings, the new Medicare prescription drug benefit (Part
D) was cited as an example of the complexity of the health care
system.

"It’s so complex. You wake up
one day and your contract has been renegotiated, your numbers have
changed, and your providers have changed. There are too many rules
and too much bureaucracy."

Linked to confusion about the health care system was the
lack of useful information to help individuals navigate the health
care system. Individuals wanted to have access to understandable
medical information to help them make educated decisions about their
health care. Many participants discussed their desire to partner with
their health care provider in making health care decisions. Participants
noted that sometimes it was very hard to find any information, although
we also heard from some participants that information was available
if one knew where to look. People often were not sure where to go
to find what they needed. The desire for information is not unique
to Working Group community meeting participants. According to a 2005
Gallup Poll, a slim majority (51 percent) of individuals said they
do not have enough information about hospitals and other health care
facilities to make educated choices for health care services. 11

Participants mentioned that they or others were not always
treated with respect or dignity. Examples of problems people
encountered included a lack of effective communication, discrimination
by race or ethnicity, long wait times, and overcrowded emergency rooms.
In a number of locations, meeting participants discussed how they
had encountered or knew of barriers due to race or ethnicity, language,
lack of cultural sensitivity, and lack of health insurance.

"It’s often more stressful to
deal with the insurance company than it is to deal with the disease."
(Des Moines meeting)

"There should be no
waiting period before becoming eligible for coverage."
(Lexington meeting)

Participants frequently cited barriers to care related
to their insurance coverage. People in community meetings
mentioned that they have experienced problems getting care due to
health insurance rules. For example, some services were not covered
due to pre-existing conditions. Participants also discussed problems
related to needing to go through an insurer’s gatekeeping requirements
to receive referrals that sometimes were denied. A number of participants
spoke of problems with the portability of health insurance under the
current system. Within the employer-based health insurance system,
someone who changes jobs might be forced to switch insurance and could
lose access to their health care provider if that provider is not
in the new network. Participants in the Billings community meeting
noted that limited provider networks created access problems in Montana,
a large but lightly populated state. In the Baton Rouge community
meeting, participants noted that the experience from the hurricanes
in the summer of 2005 brought to the forefront the need for major
emergency preparedness in all aspects of the health care system, including
among insurance providers.

The second question asked of community meeting participants about health
care delivery relates to their priorities for getting needed care:

The responses to this question built on the answers to the previous
question about problems getting care. The primary themes related to
affordability, accessibility, and forming mutually respectful relationships
with providers.

Participants told the Working Group that they want to feel
secure knowing that when they or their families need care, they can
get it without becoming impoverished. Discussants frequently
mentioned that it was important that their out-of-pocket costs for
health care not be unreasonably high. Participants said people should
have to pay some amount, but they generally also said that patients
of all income levels should be able to receive needed care without
costs being a barrier.

"I feel like we are only as good as
our weakest link, and so many people can’t afford care."
(Fargo meeting)

Participants wanted all Americans to be able to get the
right health care, at the right time, in a respectful manner. Access
for everyone emerged as a common theme across meeting sites. Some
meeting participants said that receiving "the right health care"
meant that medical decisions would not be based on factors such as
a person’s age. Many participants decried making medical decisions
on the basis of cost rather than medical need, but did want the care
they receive to be delivered in a cost-effective manner. Participants
expressed the need to have care received in a coordinated and timely
manner. Among other factors, getting the right care in a respectful
manner involved having a provider who was courteous and could communicate
well. As stated in meetings from Charlotte to Seattle, participants
believed that care should be sensitive to the needs of different cultures.
The desire to be treated with respect has also been shown to be highly
valued in other national surveys. A 2004 Wall Street Journal/Harris
Interactive poll asked what qualities people believed were extremely
important from the doctors who treat them; some of the most popular
responses related to the medical provider’s interpersonal skills—such
as being respectful (85 percent) and listening carefully to health
care concerns and questions (84 percent). 12

Participants noted that being able to choose and maintain
a stable, long-term relationship with a personal health care provider
was critical. Individuals at meetings throughout the nation
reiterated the importance of the provider-patient relationship that
they believed should not be affected by whether a person switches
jobs or changes health insurance. In the Phoenix community meeting,
participants valued being able to choose a provider that would listen
to them and provide "true" care, rather than just writing
out a prescription. They wanted to be able to keep their health care
provider even if they changed insurance carrier. In a number of locations
(such as at the meetings in Orlando and Detroit), participants also
discussed the importance of choosing a specialist. Participants at
the community meetings told the Working Group that they placed a high
value on having a "medical home" in which they can spend
individual time with a provider. On the other hand, some participants
at other meetings, such as San Antonio, expressed a willingness to
forego some choice of primary care physician in exchange for lower
costs or higher quality care.

How should health care coverage be financed?

Community meetings tended to devote a substantial amount of time
to questions related to financing health care and controlling health
care costs. The first of five questions that were commonly used in
community meetings asks participants their opinion on whether everyone
should be required to enroll in basic health care coverage:

"Should everyone be required to enroll in basic
health care coverage, either private or public?"

Meeting participants had interesting discussions in response to this
question:

Although the results differed across meeting sites, a majority
of participants (ranging from 55 percent to 88 percent in the community
meetings) believed that everyone should be required to enroll in
either private or public "basic" health care coverage.
Support for some form of mandated coverage is displayed in Figure
4. Fewer than half (47 percent) of the Working Group poll respondents
agreed or strongly agreed with requiring everyone to enroll in health
coverage, and another 21 percent said they were "neutral."
Over 80 percent in the University town hall meeting said everyone
should be required to enroll in basic (public or private) health
care coverage.

Figure 4 (table):

Should everyone be required to enroll in basic health care
coverage, either private or public?

Note: Los Angeles, New York, and Hartford are not included in this
table. In the Los Angeles meeting, the responses were modified based
on participants’ comments in the meeting. As a result, only
16 percent answered "yes" to the question, while 78 percent
of the participants chose a third option that was offered by participants—that
everyone automatically would have coverage under a national system,
so, according to participants, the question was not applicable. For
the same reason, the question was not completed in the New York meeting.
In the Hartford meeting, the majority of participants abstained.

"Enrolling everyone in a single pool
would spread costs and yield savings."
(Providence meeting)

"There should be progressive
rates for health care, based on ability to pay, through income
taxes, as part of a single- payer system."
(Hartford meeting)

"All individuals should
carry their own health insurance as they do for car and property.
Insurance companies should be forced to insure individuals rather
than corporate entities and employer groups."
(Comments submitted to CHCWG Internet "What’s Important
to You?")

Several common themes emerged when individuals discussed why they
supported requiring everyone to have health care coverage. Some participants
expressed the opinion that those who are able should pay their fair
share. At meeting sites throughout the country, individuals made the
analogy to the law that requires everyone who drives to have automobile
insurance. They believed that health coverage should be treated similarly
since everyone uses health services. Additional analogies included
laws requiring seat belt use and vaccinations, as expressed by meeting
participants in Miami. Participants in community meetings in places
such as Jackson and Denver that supported an "individual mandate"
(in other words, a law requiring all individuals to have health insurance
coverage) said it would be consistent with the philosophy of individual
responsibility.

Younger Americans Weigh in on the Issues

Over 100 students in an undergraduate public
health class at Purdue University participated in the University
town hall meeting as part of a class assignment. They completed
the University town hall poll, and explained their responses to
questions about policy options in essay questions.

Compared to older respondents, the students were less likely to
describe the health care system as being in a state of crisis
(6 percent) or having major problems (61 percent). Most (88 percent)
agreed or strongly agreed that it should be public policy that
all Americans have affordable health care insurance or other coverage,
and most (72 percent) said coverage should be provided for everyone,
for a defined level of benefits. The students also opted, by a
majority of 70 percent, for mandatory enrollment in some form
of public or private coverage.

The majority (57 percent) thought some people should be responsible
for paying more for coverage than others, with respondents most
likely to state that the criteria for paying more should be either
health behaviors or income. The most important priorities identified
by the students for public spending on health and health care
in America were guaranteeing that all Americans get health care
when they need it through some sort of private or public program
and investing in public health programs to prevent disease, promote
healthy lifestyles, and protect the public during epidemics and
disasters.

Although strong support for an "individual mandate" was
found at each of the meetings, some participants disagreed. Others
objected to the way the question was worded since they said it assumed
implicitly that a national health care system would not exist. In
fact, at the community meeting in Los Angeles, the vast majority of
participants supported a new "third" option: that everyone
automatically would have health coverage and access to care under
a new national system. Participants who disagreed with the individual
mandate concept expressed concerns that it would give greater power
to the government and would undermine concepts of individual freedom.
Someone at the Billings meeting noted, "[Montanans] don’t
like to be told what to do." Meeting participants also expressed
uncertainty about how undocumented persons or non-citizens would be
treated in the individual mandate system, with some saying these individuals
should receive care, others maintaining that non-citizens should not
be entitled to coverage.

The next commonly asked question related to whether people should
pay more for health care and, if so, whether the amount they should
be required to pay should be influenced by income or other factors:

"Should some people be responsible for paying more
than others? What criteria should be used for making some people pay
more?"

In almost every community meeting, a majority of participants
supported the notion that some individuals should be responsible
for paying more for health care than others. The most commonly mentioned
criterion for paying more was income, but varying payment by income
was supported by the majority of participants in fewer than half
of the meetings where this question was discussed. (See Figure 5.)

However, in many community meetings, no consensus emerged regarding
who should pay more, as shown in Figure 6.

The most popular choice of criteria was income. In other
words, those with higher incomes should pay more than those with
lower incomes. Some participants argued that those with very low
incomes should not have to pay anything for their care. A July 2006
Wall Street Journal Online/Harris Interactive Poll found that 39
percent of adults agree that the higher someone’s income is,
the more he or she should expect to pay in taxes to cover the cost
of people who are less well off and are heavy users of medical services.
13

The next most popular criterion often was health behaviors.
Such a system could be structured either by reducing health insurance
costs for those who practice healthy lifestyles (for example, exercising
regularly, not smoking, wearing seat belts, etc.), or by increasing
health care co-payments or premiums for those who practice unhealthy
behaviors, such as smoking. (In three of the community meetings,
the choice "other" was changed to "other/combination
of factors," which could include both income and health behaviors,
as well as other factors.) According to a Wall Street Journal
Online/Harris Interactive Poll conducted in July 2006, more than
one in three agreed (35 percent) but another 35 percent disagreed
that it is unfair to require the majority of people who are healthy
to pay for most of the cost of treating those who are sick and heavy
users of hospitals and doctors. 14

Note: This question was asked only in the above cities. In most meetings
where this question was asked, participants were also asked which criteria
should be used. In some meetings, however, only the question about criteria
was asked. See the next question below.

Over 80 percent of respondents in the University town hall meeting
said that some people should be responsible for paying more for coverage
than others, and about 71 percent said income should be used as a criterion
for making people pay more.

Figure 6 (table):

What criteria should be used for requiring some people to pay
more?

Location

None—everyone should pay same

Vary by Family size

Vary by health behaviors

Vary by income

Other

Other/ Combination

Orlando

21%

6%

15%

41%

17%

Not asked

Baton Rouge

6%

15%

27%

44%

8%

Not asked

Memphis

15%

3%

11%

58%

14%

Not asked

Charlotte

12%

1%

27%

32%

27%

Not asked

Jackson

26%

4%

19%

38%

13%

Not asked

Denver

16%

4%

16%

57%

8%

Not asked

Los Angeles

20%

4%

11%

51%

15%

Not asked

Providence

20%

2%

27%

45%

6%

Not asked

Indianapolis

16%

4%

29%

47%

5%

Not asked

Detroit

12%

7%

7%

69%

7%

Not asked

Phoenix

26%

2%

12%

52%

8%

Not asked

Des Moines

17%

4%

16%

61%

3%

Not asked

Philadelphia

8%

5%

7%

70%

10%

Not asked

Billings

12%

7%

29%

44%

8%

Not asked

Fargo

6%

1%

11%

21%

--

61%

Little Rock

11%

5%

6%

15%

--

62%

Tucson

18%

0%

18%

50%

13%

Not asked

Sioux Falls

13%

3%

23%

10%

--

52%

Salt Lake City

9%

4%

23%

59%

6%

Not asked

Note: Figures may not add up to 100 percent due to rounding. Question
was not asked in Kansas City, Seattle, Miami, Albuquerque, Hartford,
Las Vegas, Eugene, Sacramento, San Antonio, New York, Lexington, or
Cincinnati.

On the Working Group poll, there were multiple questions about how
higher income people might pay more for coverage. About 40 percent (38
percent) of respondents agreed or agreed strongly that everyone should
pay the same for health insurance, while 44 percent disagreed
or strongly disagreed. When asked whether people with higher
incomes should pay higher premiums for employer-sponsored health insurance,
37 percent agreed or strongly agreed, while 43 percent of
respondents disagreed or strongly disagreed. Moreover,
about one-third (34 percent) of respondents agreed or strongly agreed
that higher income people should pay higher premiums for health insurance
they buy themselves, compared to 45 percent who disagreed or strongly
disagreed.

The level of support for higher-income people paying more for health
insurance they purchase themselves was similar across education levels
of the people responding to the Working Group poll. A large
share of respondents disagreed or strongly disagreed. These
findings may reflect the view, also heard at many meetings and in comments
submitted via the Working Group poll, that there is some support for
higher contributions from higher-income people, but there is less support
for direct income-related cost-sharing or premiums than there is for
contributions to a national coverage system through some form of progressive
tax, as discussed below.

According to a recent Los Angeles Times/Bloomberg survey 34 percent
of adults believe that it is the government’s responsibility to
ensure that all citizens have health insurance and income for retirement,
while 28 percent believe that it is the employer’s responsibility
and 28 percent believe that it is the individual’s responsibility.15

The following question generated substantial debate at many of the
meetings:

"Should public policy continue to use tax rules to
encourage employer-based health insurance?"

As shown in Figure 7, the percent of individuals who agreed with this
question varied greatly from meeting site to meeting site. In the Detroit
community meeting, only 23 percent of participants supported a continuation
of the use of tax rules to encourage employer-based health insurance,
while 87 percent of those at the Baton Rouge community meeting agreed
with the policy. In a number of meetings, some participants abstained
from answering the question, in many cases because of frustration with
the way the question was worded, as was the case with the previous two
questions. In five of the community meetings, an "abstain"
option was provided to participants.

A different question, focusing on whether employers should be given
additional incentives to expand coverage, was asked in both
the Working Group’s poll and the University Internet town hall
meeting. Support for tax incentives for employer-sponsored coverage
as a means of expanding coverage was relatively high. Almost 70 percent
(69 percent) of Working Group poll respondents and 61 percent of University
town hall meeting respondents agreed or strongly agreed with the strategy.

Figure 7:

Should public policy continue to use tax rules to encourage
employer-based health insurance?

Note: Question was not asked in Sacramento, New York, or Sioux Falls.
* "Abstain" option provided.

"I do believe all employers large and
small should give their workers insurance. There should be programs
or better tax cuts for those employers."

"[Expand] tax incentives for companies that provide health
care benefits for their employees. Small companies should be able
to join together to take advantage of group rates. Corporations
like Wal-Mart should be penalized for not providing decent health
care benefits for its employees."

"If employers are to continue to provide coverage, all employers
must participate, nationwide."

"I think that placing the burden of health care on employers
makes American businesses less competitive in the global market.
At the same time, I think that placing the burden of paying for
health care on individuals will ultimately drive up the cost of
care by forcing the poor and middle-income among us to rely on costly
emergency services that hospitals cannot ethically deny based on
inability to pay, rather than cheaper preventive care which they
can."

"We must sever the relationship between health insurance and
employment. Employers should not bear the cost; it is impacting
our competitiveness in the global market and it leaves huge gaps
in which persons not employed in a company providing health insurance,
are forced to bear huge costs of non-group insurance or, most likely,
go without insurance at all. The rising percentage of uninsured
is a tragedy in itself because these people frequently go without
needed health care until they reach crisis. In addition, we all
pay for the uninsured through higher and higher insurance premiums.
Our system must be completely overhauled and redesigned to provide
universal coverage with buy-in by all who have the means and a safety-net
for those who can not."
(Comments submitted to CHCWG "What’s Important to You?")

Views about employer-based coverage did not generally reflect
a deep distrust of employers, but instead were intertwined with broader
concepts of health reform. The extent to which participants
at a meeting may have been more heavily focused on fundamental reform,
like a single-payer system, affected the group discussions about employer-based
coverage. An analysis of Internet and mailed-in, open-ended responses
to the question about changing the way health care is financed, as
well as comments from participants at some community meetings, revealed
at least four—sometimes overlapping—categories of responses.

"The current system should be maintained or bolstered,
either on an ongoing basis or as part of a more comprehensive system."
Some meeting participants supported a clear role for
employers and a continuation of the current tax rules for employers.
Some participants who supported retention of these tax rules argued
that they needed to be applied fairly, with small businesses needing
additional incentives. Meeting participants who supported comprehensive
reform through some type of national plan told the Working Group that,
in the absence of a national plan, employers would need to be responsible,
with tax breaks provided to assist small businesses. Without a national
plan, participants worried that people across the country would lose
coverage through employers dropping insurance. In the community meeting
in Los Angeles, participants who supported continuing the current
tax system did so because they believed it encourages employers to
provide coverage that they might otherwise not have an incentive to
provide. They also felt that the system leads to higher employer productivity
and helps promote shared responsibility.

"Employer-based insurance is not sustainable and
is too expensive." Many participants felt the nation
should move away from current tax rules that favor employer-sponsored
coverage. Even with the current tax breaks, health care costs continue
to rise rapidly, and both businesses and employees are footing ever
larger and unsustainable expenditures. Some meeting participants believed
that the system of employer-based health insurance needs to be replaced
to make U.S. industries more competitive. At least one person noted
that the employer subsidies were invisible to the average citizen,
unlike Medicare or Medicaid, whose costs are frequently cited. Other
participants noted that they were afraid to leave their jobs because
of fear of losing health insurance or paying higher premiums. Those
who opposed the current tax breaks cited a lack of equity in the current
employer-based insurance system, a system that, as long as it exists,
means that health care, as stated by someone at the Indianapolis meeting,
will be, "an imperfect patchwork full of gaps."

"The whole system should be changed fundamentally,
but employers should contribute through some form of taxation or contributions
to a pool." Other participants indicated an interest
in a non-employer based system, but one in which the employers are
still involved. For example, in the Des Moines community meeting,
a participant referred to the employment-based system as "…outdated
and the money saved from not having an employer-based system could
go towards higher salaries and/or taxes to create a new system."
Some participants at different meetings supported fundamental change
to the system, but believed that a transition period should be implemented
during which employers would still contribute to the system.

"We need to have one single pool of
Americans who are insured. This would help spread their risk and
everyone could be covered. Employers could contribute to the costs,
but individuals should be able to contribute on their own."
(Comments submitted to CHCWG Internet "What’s Important
to You?")

"Employer-based insurance is unfair, inequitable,
and inadequate." A number of participants discussed
other aspects of the employer-based system that were not working.
For example, participants brought up the fact that some employers
are going around the current tax system by hiring only part time employees,
to whom they are not required to offer full benefits. In the Los Angeles
meeting, many participants supported a government-run universal health
care system because they felt that the current employer-based system
is unfair. They expressed concerns that it excludes self-employed,
unemployed, and part-time workers, and favors large corporations.
These participants supported replacing the employer tax incentive
with another type of tax (such as an income or payroll tax). At several
meetings and in Internet comments, some called for a national value
added tax(1) or national sales tax. A large
number of participants expressed the opinion that access to care should
not be tied to insurance coverage.

"Employer-sponsored insurance worked
when it was a perk, an extra offered by employers. But now coverage
is a necessity, not a privilege."
(Billings meeting)

At some meetings, participants were asked what the responsibilities
of individuals and families should be in a health care system. Although
some of these topics will be discussed under the next question typically
asked in community meetings ("What can be done to slow the growth
of health care costs?"), the following section provides a brief
summary of three of the most common responses to the question:

"What should the responsibilities of individuals
and families be in the health care system?"

Three of the most common answers heard by the Working Group in response
to this question were the following:

At most meetings, participants stressed the importance of
preventive care to reduce health care costs. Preventive care
includes getting important screenings, exercising regularly if possible,
and following a healthy diet. Some individuals said that practicing
preventive care would lower health care costs.

Participants at most meetings believed that individuals
have a responsibility to manage their own care and use of services.
Participants told the Working Group that doing so involves educating
oneself, possibly through attending health education classes. It also
involves being proactive in seeking better care and becoming wise,
informed consumers of health care services and following treatment
regimens. However, a number of participants noted that some people
are better equipped to be informed consumers than others.

In many meetings, participants mentioned that individuals
have a social responsibility to pay a fair share for health care.
Participants in the Memphis and Las Vegas meetings, among others,
mentioned that, in a universal health system, this would include paying
appropriate and possibly additional taxes.

The Working Group poll also shows some support for strategies that
focus attention on the costs and appropriate use of health care. A majority
of respondents either agreed (37 percent) or strongly agreed (19 percent)
that we should all pay for part of our health care costs so that we
will be more careful about how we use health care services.

Hearing from self-employed small business owners

The National Association of Realtors hosted
a community meeting during their annual legislative conference on
May 16, 2006, in Washington, DC, to enable the Citizens’ Health
Care Working Group to hear from these self-employed small business
owners from around the country. Participants at this meeting sought
to identify solutions for the problems specific to self-employed
small business owners. They recognized that more than one in four
of the nation’s 1.2 million realtors have no health care coverage,
while many others are only a single health incident away from having
their livelihood destroyed by high health care costs.

Recurring themes in this meeting included a desire to have protection
from financial ruin, having access to affordable care, and increasing
the information available for patients on cost and quality to enhance
their decision-making capabilities. They emphasized the need for
a level of security in the health care system, saying that "we
need something that ensures that if we become very ill, it doesn’t
take away our livelihood or what we’ve worked so hard to earn
all our lives." While most participants agreed that everyone
should have access to basic health care services, they were rather
evenly divided on whether or not people should be required to have
health care coverage. One participant said that "at first I
was going to say no (to a requirement), but then I thought, if they
aren’t required to sign up for it then the only time they
will get in the system is when there is emergency care and that
will cost us more." Desiring to keep health care "in the
competitive arena," participants talked about the need to have
greater transparency in costs, standardization of forms, and understandable
information to enable them to be better patients. There was a clear
sentiment at this meeting to limit government involvement, with
participants asking "has it ever improved anything if the government
gets involved and standardizes it?"

The next "typical" meeting question asked participants about
ideas for reducing the growth of health care costs in this country:

"What can be done to slow the growth of health care
costs in America?"

Participants had a variety of ideas about how they would slow the growth
of health care costs. Throughout the meetings, common themes emerged:

Participants frequently stated that the problems of high
costs rest with "price setters"—namely, prescription
drug companies, insurers, and for-profit providers. In meetings
throughout the country, participants mentioned the desire to limit
profits in the health care sector. Some participants also noted that
allowing the government broader authority to negotiate prices with
pharmaceutical companies would reduce Medicare costs. The Working
Group poll showed strong support for government setting limits on
prices for health care products such as prescription drugs or medical
devices; just over 70 percent of respondents strongly agreed (39 percent)
or agreed (32 percent) with these government-set limits. The general
lack of trust of for-profit health care expressed in the community
meetings is consistent with other national survey findings. For example,
a December 2003 Wall Street Journal Online Health Care Poll found
that most of the public do not view health care as a business that
should be driven by the profit motive, and only 22 percent would prefer
that for-profit insurance provide most health insurance; the findings
indicated a preference for government (31 percent) or non-profit organizations
(25 percent).16

A commonly expressed view was that a simpler system would
result in lower administrative costs. Participants believed
that a more straightforward health care system would reduce administrative
costs by eliminating duplication of services. At a number of meetings
throughout the country, many individuals advocated a single-payer
system to eliminate the middleman, possibly one structured like Medicare
or similar to the public school system. Under this type of system,
everyone would pay taxes to support the system, even though, as with
education, they might not use the services. Participants advocating
the single payer concept said it would be the most efficient way to
organize health care.

"I paid over $12,000 in expenses (not
including legal fees) to collect $12,500 in medical expenses because
insurers were arguing about who was responsible. Everyone wants
to avoid paying. It would be vastly cheaper to adopt any of the
European systems."

"I think we'll
finally, inevitably, follow the lead of every other Westernized
nation and institute some form of extensive public health care system
– I think it's the most efficient system, and the one that
gives the best care to the most people. The biggest problem I see
with the system as it now stands is that we as a society spend a
huge amount of money putting a profit in the pockets of the ‘middleman’
in the system—the insurance companies. That's why we spend
50% more of our GNP on health care than other nations do while getting
worse care, and it's absurd."
(Comments submitted to CHCWG Internet "What’s Important
to You?")

Some support exists for investment by providers and the
private sector in health information technology to increase system
efficiency. At a number of meetings, participants supported
increasing the availability of electronic medical records. Greater
investment in health information technology and moving to an integrated
system of electronic medical records could improve administration
and treatment and reduce medical errors, according to views commonly
expressed at the meetings. More than 70 percent (71 percent) of respondents
to the Working Group poll supported more investment by doctors, hospitals,
and other providers in health information technologies as a means
to improve quality and increase administrative efficiency. (By comparison,
a 2005 Wall Street Journal Online/Harris Interactive poll found that
78 percent of the public supported doctors’ use of electronic
medical records.)17

A concern discussed at some meetings was privacy of the electronic
medical records, which is highlighted in recent national surveys.
For example, a 2005 Harris Interactive poll found that 70 percent
of Americans are very or somewhat concerned that personal medical
information might be leaked due to weak data security, and the public
was evenly divided on whether the potential benefits of electronic
medical records outweigh the potential risks to privacy.18

Public investment in health information technology was not identified
as among the priorities for public spending on health and health care
by most Internet poll respondents (see Appendix C).

Participants expressed general support for individuals
playing their part in controlling utilization and costs.
Individuals have a responsibility to be informed health care consumers
and comply with recommended treatments. To this end, participants
suggested several related ideas:

Individuals would like information about how to use
health care better and more effectively. For example,
those with chronic diseases could use more information to properly
manage their treatments.

At some meetings, participants supported providing incentives
to patients to engage in healthy behaviors. Some participants
supported the idea of rewarding people who practice healthy behaviors
(for example, not smoking, or getting recommended health screenings).
On occasion, participants also discussed the notion of penalizing
people who engage in unhealthy lifestyles. The type of unhealthy
behavior in question affected participants’ opinions, consistent
with other national surveys. According to a 2005 Wall Street Journal
Online/Harris Interactive poll, the majority of Americans supported
the idea of smokers, those who do not wear seat belts, and those
who drink alcohol heavily paying more in health insurance costs;
however, the same poll found strong opposition for charging more
to those who are overweight or who do not exercise regularly.19
According to a 2006 Wall Street Journal Online/Harris Interactive
poll that compared results from the same poll in 2003 to the results
in from the 2006 poll, in 2006 53 percent of adults agreed that
it is fair to ask people with unhealthy lifestyles to pay higher
insurance premiums than people with healthy lifestyles; while
in 2003 only 37 percent of adults agreed.20

Participants expressed preferences for using medical
evidence to decide which services are covered and provided.
Many participants discussed the importance of focusing on evidence-based
medicine.

There was general support for controlling prescription
drug costs by limiting direct-to-consumer advertising of prescription
drugs and using more generic drugs, when medically appropriate.
Participants at many meetings expressed the desire to limit or
prohibit direct-to-consumer advertising of prescription drugs,
which could reduce the over-use of heavily-advertised drugs and
slow the growth of health care costs. Some people mentioned ideas
to make generic drugs available more quickly in the market; for
example, Orlando community meeting participants suggested reducing
the length of time of the exclusive patent rights of pharmaceutical
companies.

Support also existed for limiting expensive yet "futile"
end-of-life care and instead providing palliative care.
Participants at meetings generally recognized the high costs associated
with certain end-of-life services, some providing little value
to the patient despite their high costs. At the same time, they
stressed the importance of pain management, hospice care, and
other support services to improve the quality of the last days
of life. Better communication with patients near the end of life
was considered to be an important step in controlling these costs.
Participants in some meetings stressed the importance of living
wills and medical directives that detailed people’s wishes
for treatment if they were too ill to communicate. At many meetings,
similar concerns were expressed about the effectiveness and costs
of care for very fragile newborns.

"We should have the decency to honor
end of life by not pumping millions into the last days but rather
encouraging high quality comfort care."
(Sioux Falls meeting)

In almost all community meetings, participants expressed
the belief that changing the culture from sick care to well care—namely,
by focusing on prevention, wellness, and education (in general, and
health education in particular)—will reduce health care costs.
Participants broadly supported greater emphasis on prevention as part
of a "culture of wellness" in the health care system. A
number of participants in community meetings across the nation (including
Des Moines, Fargo, Salt Lake City, Las Vegas, and others) emphasized
the need for education of both children and adults to make this culture
possible.

"If we want to bring the cost of health
care down, then ultimately, we need to reduce the burden of disease.
We need to reduce the need to spend money rather than figuring out
how to redistribute the money. Otherwise the system will remain
broken regardless of how we want to pay for it."
(Indianapolis meeting)

A commonly expressed view was that better use of advanced
practice nurses and other non-physicians could save money and improve
quality. In some meetings, participants supported the increased
use of care provided by health professionals other than physicians
including greater use of home-based care.

Participants believed that investing in public health would
pay dividends in terms of reducing health care costs. Some
people discussed providing more funding for community health centers
and for public health more generally. They believed that doing so
could reduce racial differences or disparities in health care, and
could effectively reduce overall system costs.

Support for limits on malpractice was expressed at some
community meetings. Some participants discussed decreasing
malpractice costs.

End-of-life care has surfaced
at virtually every community meeting as an issue that encapsulates
many of the frustrations with health care in America. Sometimes
meeting attendees discussed the need for hospice care in the basic
benefit package. Sometimes participants talked about exchanging
expensive measures of questionable efficacy for the dying for general
improvements in access to care. Usually, the speaker raising the
issue has been a bit tentative. "I’m not sure how to
phrase this…" or "This sounds clumsy…"
Death is a difficult topic among family and friends; it’s
also difficult in a policy context.

At its Boston hearing, the Working Group heard a panel of experts
on end-of-life care. This discussion was compelling, and members
asked that a community meeting be held on the topic (information
on the presentation can be found in Appendix E). This special topic
meeting was held March 31, 2006 in Hanover, New Hampshire. About
120 people attended. "Living Well through the End-of-Life"
was the theme of the meeting. The last chapter of many people’s
lives requires support and assistance, but often what is needed
to live well is not medical in nature. Transportation, personal
care, and help with meals and cooking are all needed. What people
attending the meeting feared most about their final days (or those
of someone close to them) were intractable pain, "prolongation
of death," and losing personal control. They identified potential
challenges related to "getting the system to work for you when
you are dying" or "graceful surrender." What people
wanted most from the medical system was to have their choices honored,
good pain relief, and respect from health professionals so they
could maintain their dignity.

The majority believed that family and friends are the primary sources
of such help, but that some paid assistance should also be available.
People would like respite services for the principal care provider
and a contact person for coordination of community help. "Care
has to be taken out of the medical system and accommodate what happens
in the community." Most people (69 percent) wanted to die at
home. Close to 85 percent believed that other choices could be acceptable
if certain elements of care were well managed.

When asked what policy advice they’d give their Senators,
participants had many specific suggestions, such as realigning financial
incentives so that physicians could be encouraged to spend more
time talking to patients and a request to revisit Medicare hospice
payment practices. However, suggestions quickly began to mirror
what has been heard in other meetings. "As a health care
consumer, I want appropriate, timely, comprehensive care from conception
to death and I would be willing to pay an additional modest percentage
of income across my working life to achieve this."

A value added tax is a tax,
levied at each stage of production, on the added value in each stage
as firms produce goods or services. It is similar in some respects
to a sales tax. Many industrialized nation employ various types
of value added taxes. (See Bickley, James M. CRS Report for Congress
Value-Added Tax: A New U.S. Revenue Source? Washington D.C: Congressional
Research Service, August 22, 2006. Accessed at http://opencrs.cdt.org/rpts/RL33619.pdf.)

What trade-offs are the American public
willing to make in either benefits or financing to ensure access affordable,
high-quality coverage and services?

The last of the four questions that the legislation directed the
Working Group to ask the American people is about trade-offs they
are willing to make so that everyone has access to affordable, high-quality
care. In community meetings, the "typical" structure was
to ask participants to discuss their willingness to pay to achieve
this goal, evaluate the most important priorities for public spending
on health care, consider specific trade-offs the public would be willing
to make, and then to evaluate potential approaches for improving access
to affordable, high quality health care for all Americans. In many
meetings, time constraints or the desire by participants to reiterate
their support for broad system reform precluded discussion of some
of these questions.

Many comments submitted to the Working Group via the poll provide
additional context for understanding what we heard about trade-offs.
Although worded in a variety of ways, the single most common response
to the question about trade-offs can be summarized as "no trade-offs."
The discussions at the community meetings provided context for what
people really were saying, which is far more complicated.

The discussion at meetings was divided into several parts. One set
of deliberations at the meetings focused specifically on paying for
expanded coverage.

"That is too broad a question. There
is the wealthy American public who have lots of options right
now. There is the less wealthy American public who have enough
income to take some of the available options. There is the working
American public who can just barely afford any available options.
And there is the American public who can not afford any of today's
health care options. And each group will have very different ideas
about what they are willing to give up or ‘trade-off’
to get affordable, good quality health care. Even the concept
of ‘quality’ health care is a relative term -- any
reasonably trained and mostly competent doctor looks good when
your choice is that doctor or no treatment at all. What all Americans
should want is at least the quality and availability of care that
countries like Canada, France, England, etc. offer."
(Comments submitted to CHCWG "What’s Important to You?")

"Eliminate profits in the health care system
to pay for universal coverage."
(New York City meeting)

"How much MORE would you be willing to pay (taxes,
premiums, co-payments, or deductibles) in a year to support efforts
that would result in every American having access to affordable, high
quality health care coverage and services?"

In most meetings as well as on the Working Group poll,
a majority of participants expressed a willingness to pay more to
assure that everyone had access to affordable, high quality health
care. Overall, about one in three (29 percent) said they were willing
to pay $300 or more per year. Sizable shares of participants
expressed a willingness to contribute some additional amount each
year toward the stated goal. (See Figure 8.) Although the size of
the groups varied, some participants at all meetings said they would
be willing to pay an additional $1,000 or more in a year. The Working
Group poll indicated that 12 percent would be willing to pay $1,000
or more per year (in taxes, premiums, or deductibles) to support
efforts that would result in access to affordable, high-quality
health care services and coverage for all, and 17 percent would
be willing to pay an additional $300 to $999. Another 19 percent
said they did not know, and 13 percent said they would not be willing
to pay anything extra.

"For those that already have health
care, I believe many are willing to pay a little more for that
benefit if they can be guaranteed that the extra would be put
towards providing health care for those less fortunate; most of
us have been in the position of having no health care at one time
or another in our lives. For those that don't currently have health
care, there can't be much they can trade".
"I think that most people would be willing to accept a national
value added or national sales tax to fund a nationalized medical
system that treats all legal citizens fairly and equally, without
financial or any other kind of discrimination."

"Phase it in. Universalize a small sector of health care--for
example, preventive care--before trying to redo the entire system.
If the public learns to trust a small sector of tax-financed health
care, it will be more open to greater change."

"It should be underwritten by the government, with sliding
scale of payments made by individuals through taxes - people who
make the most should pay the most to insure that health care is
available for all; employers should also contribute through the
taxes they pay."
Comments submitted to CHCWG "What’s Important to You?")

In the Working Group poll, the amount they were willing to pay
was fairly consistent across age; however, persons with the highest
levels of education (those with graduate degrees) were more likely
to be willing to pay $1,000 or more than those with less education,
a finding that could indicate that those likely to have more money
are willing to pay more. It may also reflect that those with higher
levels of education typically have richer employer-sponsored insurance
packages, face lower out-of-pocket payments, and therefore have
not already reached their limit in terms of willingness to pay.
At the meeting with realtors (see "Hearing from self-employed
small business owners" text box presented earlier), where few
have any employer-sponsored insurance and face high premiums in
the individual market, a large percentage were not willing to pay
anything more, even though they earn relatively high incomes. Even
so, in the 28 meetings where the question was asked, at least 43
percent of participants indicated some willingness to pay more to
achieve this goal.

Figure 8 (table):

Amount Willing To Pay in a Year So That Every American Has
Access to Affordable, High-Quality Health Care

Location

$0

$1-$99

$100-$299

$300-$999

$1,000+

Don’t Know

Kansas City

7%

12%

19%

24%

25%

14%

Orlando

18%

11%

20%

15%

17%

20%

Baton Rouge

9%

20%

20%

26%

20%

7%

Memphis

31%

2%

4%

13%

31%

19%

Charlotte

45%

8%

11%

10%

16%

11%

Jackson

34%

16%

15%

13%

5%

18%

Denver

12%

16%

17%

24%

25%

6%

Los Angeles

38%

14%

9%

10%

11%

19%

Providence

24%

8%

21%

16%

24%

8%

Indianapolis

12%

15%

15%

16%

22%

20%

Detroit

10%

13%

15%

21%

33%

8%

Albuquerque

22%

8%

18%

18%

24%

10%

Phoenix

19%

15%

20%

19%

20%

7%

Hartford

20%

10%

13%

27%

22%

8%

Des Moines

14%

12%

15%

31%

20%

9%

Philadelphia

9%

12%

12%

13%

28%

25%

Las Vegas

15%

18%

21%

20%

16%

11%

Eugene

13%

12%

12%

18%

33%

12%

San Antonio

8%

15%

23%

20%

19%

15%

Billings

15%

16%

19%

19%

21%

10%

Fargo

11%

16%

30%

16%

13%

14%

New York

25%

3%

6%

13%

36%

16%

Lexington

11%

15%

18%

29%

20%

6%

Cincinnati

24%

19%

15%

10%

12%

19%

Little Rock

14%

26%

23%

18%

7%

12%

Tucson

23%

19%

0%

29%

13%

16%

Sioux Falls

6%

16%

16%

25%

28%

9%

Salt Lake City

23%

14%

20%

25%

11%

6%

AVERAGE

19%

14%

16%

17%

19%

14%

Working Group Poll

13%

17%

21%

17%

12%

20%

Notes: Figures may not add up to 100 percent due to rounding. The
"don’t know" data for the Working Group poll includes
the one percent that did not respond. Question was not asked in
the Seattle, Miami, or Sacramento community meetings.

The next question asked the public about its views on what should
be the most important priority for public spending for health care:

"Considering the rising cost of health care, which
of the following should be the most important priority for public
spending to reach the goal of health care that works for all Americans?"

At community meetings throughout the country, participants were asked
to consider a list of possible priorities for public spending to reach
the goal of health care that works for all Americans. In some of the
meetings, participants were asked to give the most important priority
of those listed, while in other meetings participants were asked to
rate each priority on a scale from 1 (low) to 10 (high). The list
presented at the meetings generally included the following items:
guaranteeing that there are enough health care providers, especially
in areas such as inner cities and rural areas; investing in public
health programs to prevent disease, promote healthy lifestyles, and
protect the public in the event of epidemics or disasters; guaranteeing
that all Americans have health insurance; funding the development
of computerized health information; funding programs that eliminate
problems in access to or quality of care for minorities; funding biomedical
and technological research; guaranteeing that all Americans get health
care when they need it, through some form of public or private program,
including "safety net" programs for those who cannot afford
care otherwise; and preserving Medicare and Medicaid.

Although the phrasing of the question and the options given were
not exactly the same across the community meeting sites and the Working
Group poll, the top priorities were consistent:

When asked to rank or choose among competing priorities
for public spending on health, meeting participants—with few
exceptions—were most likely to rank "Guaranteeing
that all Americans have health coverage/insurance" at
the top of the list. In the Working Group poll, 64.6 percent
chose this as among the top three priorities for public spending
on health.

Other spending priorities in the list that tended to score high
included:

Investing in public health programs to prevent disease,
promote healthy lifestyles, and protect the public in the event
of epidemics or disasters

Guaranteeing that all Americans get health care when they
need it, through some form of public or private program, including
"safety net" programs for those who cannot afford
care otherwise

Guaranteeing that there are enough health care providers,
especially in areas such as inner cities and rural areas , and

Funding programs that eliminate problems in access to or
quality of care for minorities.

It is important to note that each of the eight options provided by
the Working Group likely would receive support from the public if
polled separately, even if it did not rank as the highest
priority among the group. For example, "funding the development
of computerized health information" and "funding biomedical
and technological research" generally did not rank among the
highest priorities, though discussions at Working Group meetings frequently
emphasized their importance. Similarly, individuals selecting other
options as most important (such as "guaranteeing that all Americans
have health insurance") would likely be in favor of strengthening
Medicare and Medicaid as part of the broader health care structure
that would cover all Americans.

It is also important to note that support for any of the
particular proposals could change dramatically when the list of potential
priorities was modified, as occurred in two meetings. In the Hartford
meeting, where participants were asked, "Which is your first
priority?" discussants there added a ninth priority to the list:
"Guaranteeing that all Americans have quality health care."
When this option was included in the list of options, a full
80 percent of participants selected it rather than the options ranked
highly elsewhere. For example, although the option, "Guaranteeing
that all Americans have health coverage" ranked as the second
highest priority in the list, it was selected by only 8 percent of
participants. "Guaranteeing that all Americans get health care
when they need it" also was selected by 8 percent of respondents,
and no other option generated more than one vote. Similarly, in the
Billings meeting, audience members requested a word change of one
of the choices to include "Guaranteeing that all Americans
have health care." In this meeting, participants were asked
to rate each priority on a scale from 1 (low) to 10 (high). When this
option was added, it ranked higher than any other option.

Paying More Taxes for Health Care for All:
Evidence from Other National Polls

A poll conducted in December 2004 by The Pew Research Center
for the People and the Press found that 65 percent of Americans
favor or strongly favor the U.S. government guaranteeing health
insurance for all citizens, even if it meant raising taxes (Pew);
an earlier poll conducted in August 2003 also by Pew from the same
polling group also found that 67 percent favored guaranteeing health
insurance to all citizens even if it meant raising taxes. 21

A 2003 CBS News/New York Times poll showed that 81 percent of
respondents favored using potential tax cut money to ensure all
Americans have access to health insurance, whereas 14 percent indicated
a tax cut should be a higher priority. 22

A 2003 poll found that 79 percent of Americans believed it is
more important to provide health care coverage for all Americans,
than to hold down taxes. (ABC/Washington Post). 23

The next question often asked at community meetings was met with resistance
at most meetings, sometimes by many of the participants:

"Some believe that fixing the health care system
will require trade-offs from everyone—for example, hospitals,
employers, insurers, consumers, government agencies. By ‘trade-off’
we mean reducing or eliminating something to get more of something else.
On a scale from 1 (strongly oppose) to 10 (strongly support), please
rate your support of each of the following trade-offs. What are some
other examples of trade-offs that you would support?"

In many of the meetings, the Working Group provided a list of specific
trade-offs for participants to evaluate:

Accepting a significant wait time for non-critical care to obtain
a 10 percent reduction in health care costs

Paying a higher deductible in your insurance for more choice of
physicians and hospitals (or paying a lower deductible with less choice)

Paying more in taxes to have health care coverage for all. This
could mean limiting coverage to high deductible/ catastrophic care
or, if you were willing to pay more, a more comprehensive package

Expanding federal programs to cover more people, but providing
fewer services to those currently covered in those programs

Limiting coverage for certain end-of-life care of questionable
value in order to provide more at-home and comfort care for the dying

Having government define benefits and set prices versus relying
on free market competition by doctors, hospitals, other health care
providers, and insurance companies.

"I would be more willing to pay more
in taxes to assure that everyone has access to good healthcare if
I could be assured that the medical care system was based on fair
practices and was not influencing politics. I would be thrilled
to see Americans embrace a healthier lifestyle. That is a trade-off
that doesn't cost much. People seem to believe that they can just
take a pill or wait for some breakthrough to solve their health
problems. Public schools need to bring back physical education and
increase activity, cities need to become more pedestrian/bicycle-friendly.
This country can help provide the opportunity to MAINTAIN good health
instead of fixing the problems of poor health; - it would be a lot
cheaper. I'd be willing to pay more in taxes for things like that."
(Comments submitted to CHCWG "What’s Important
to You?")

In a number of meetings, participants voiced support for limiting coverage
for end-of-life care of questionable value in order to provide more
at-home and comfort care for the dying. This option received strong
support in both the Working Group poll and the University town hall
meeting—59 percent and 63 percent, respectively, agreed or strongly
agreed with the proposal. The proposal generally receiving the lowest
level of support was "expanding federal programs to cover more
people, but provide fewer services to persons currently covered by those
programs." In the Working Group poll, for example, only 17 percent
of respondents agreed or strongly agreed with this proposal. In the
University town hall meeting, 24 percent agreed or strongly agreed.

Individuals at many, if not all, community meetings argued that there
were enough resources in the system already to achieve a goal of health
care that works for all Americans, that resources just need to be redistributed.
Most, however, did not think that the resources needed to be redistributed
away from services provided to them; rather, they wanted to see reductions
in waste, fraud, and (unnecessary) profit. In other cases, participants
thought that the trade-offs should come from outside the health arena.
For example, at the Los Angeles community meeting, participants developed
and voted on their own list of specific trade-offs they would be willing
to support. The only two choices that garnered majority support were:
(1) No trade-offs—the American people already pay more than enough
to fully fund a single-payer universal plan; and (2) Trade war for health
care—cut from defense and homeland security budgets. In Las Vegas,
the participants opted for "re-evaluating federal spending priorities."

Despite the resistance to this particular question, the meeting participants
did discuss various trade-offs (without using that term) in previous
sections of the meeting. For example, as noted above, many participants
expressed a willingness to pay more so that everyone had care. Many
participants also told the Working Group that individuals should play
a larger role in their health and health care. More than one in three
people filling out the Working Group’s Internet poll said they
would be willing to pay a higher deductible in exchange for more choice
of providers and services. This level of support for a trade-off of
out-of-pocket costs for choice was actually slightly higher than the
2004 National Opinion Research Center at the University of Chicago (NORC)
national survey finding that 27 percent of respondents would be willing
to accept a higher deductible in exchange for fewer restrictions on
use. The NORC results varied by income: 40 percent of Americans with
household income of $75,000 or more would accept a higher deductible,
compared with 23 percent with income below $25,000.24 The
Working Group was not able to analyze the relationship of income to
its participants’ responses.

The final substantive question at meetings asked people for their opinions
on a range of fairly specific yet broad proposals for ensuring access
to affordable, high quality health care coverage and services for all
Americans:

"If you believe it is important to ensure access to
affordable, high-quality health care coverage and services for all Americans,
which of these proposals would you suggest for doing this?"

As with the previous question, participants at the community meetings
were asked to evaluate a list of proposals. In this case, participants
were asked to evaluate ten proposals on a scale from 1 (low) to 10 (high).
Proposals included: offer uninsured Americans income tax deductions,
credits, or other financial assistance to help them purchase private
health insurance on their own; expand state government programs for
low-income people, such as Medicaid and the State Children’s Health
Insurance Program (SCHIP), to provide coverage for more people without
health insurance; rely on free-market competition among doctors, hospitals,
other health care providers, and insurance companies rather than having
government define benefits and set prices; open up enrollment in national
federal programs like Medicare or the federal employees’ health
benefits program; expand current tax incentives available to employers
and their employees to encourage employers to offer insurance to more
workers and families; require businesses to offer health insurance to
their employees; expand neighborhood health clinics; create a national
health insurance program, financed by taxpayers, in which all Americans
would get their insurance; require that all Americans enroll in basic
health care coverage, either private or public; and increase flexibility
afforded states in how they use federal funds for state programs—such
as Medicaid and SCHIP—to maximize coverage.

As with the question on priorities for public spending, preferences
varied somewhat in different meetings and on the Working Group poll.
Once again, however, a clear consensus emerged among these options:

When asked to evaluate different proposals for ensuring access to
affordable, high-quality health care coverage and services for all
Americans, individuals at all but four meetings ranked "Create
a national health insurance program, financed by taxpayers, in which
all Americans would get their insurance" the highest.

Three other options almost consistently ranked in the top four choices:

Expand neighborhood health clinics

Open up enrollment in national federal programs like Medicare
or the federal employees’ health benefits program, and

Require that all Americans enroll in basic health care coverage,
either private or public.

These options received high levels of support, in the community meetings
as well as the Working Group poll. The support for neighborhood health
clinics and for opening up enrollment in Medicare or the federal employees’
health benefits program was consistently high and in line with the strong
support for the Medicare program that was expressed in meetings across
the country. The responses to both the Working Group poll and the University
town hall meeting were similar to each other, as shown in Figure 9 below.
There was, however, stronger support for expanding state programs such
as Medicaid or SCHIP in the poll and the University town hall meeting
than in the 31 community meetings. The level of support in the Working
Group poll and University town hall meeting for opening enrollment in
national programs such as Medicare or the federal employees’ health
benefits program was in line with a 2005 national survey by the Employee
Benefit Research Institute that found 76 percent strongly or somewhat
favor allowing uninsured people to buy into government programs such
as Medicare and Medicaid, or into the one in which members of Congress
participate. 25

In the community meetings, the individual mandate (in other words,
requiring that all Americans enroll in basic health care coverage, either
private or public) was included as one of the options. Regardless of
when in the meeting the question was asked, this option had a fairly
high level of support, although the explanation of the concept differed
from discussion to discussion. This option ranked third in popularity
in the University town hall meeting and, in several community meetings,
it ranked higher than all other options. However, its support in the
Working Group Internet poll was below 50 percent.

Figure 9:

Responses to Trade-off Questions on Working Group Poll and
from University Internet Town Hall Meeting

How much do you agree or disagree with the following options
to assure coverage for all Americans?

% who "Agree" or "Strongly Agree"

Working Group Poll

University Town Hall Meeting

Offer uninsured Americans income tax deductions, credits, or other
financial assistance to help them purchase private health insurance
on their own

42%

35%

Expand state government programs for low-income people, such as
Medicaid and the State Children’s Health Insurance Program,
to provide coverage for more people without health insurance

68%

71%

Rely on free market competition among doctors, hospitals, other
health care providers and insurance companies, rather than having
government define benefits and set prices

23%

16%

Open up enrollment in national federal programs like Medicare
or the federal employees’ health benefit program

64%

63%

Require businesses to offer health insurance to their employees

56%

47%

Expand neighborhood health clinics

73%

79%

Create a national health plan, financed by taxpayers,
in which all Americans would get their health insurance

70%

78%

Require that all Americans enroll in basic health care coverage,
either private or public

47%

74%

Increase flexibility given states in how they use federal funds
(such as Medicaid and the State Children's Health Insurance Program)
to maximize coverage

55%

58%

Expand current tax incentives available to employers and their
employees to encourage them to offer insurance to more workers and
their families

69%

61%

The open-ended comments submitted to the Working Group provide some
additional insight into how people view the health care system, how
they want it changed, and what trade-offs they are willing to make.
More than 6,000 people (6,224) wrote responses, sometimes fairly long,
to the general questions on both the Internet as well as on paper forms
sent to the Working Group.

In general, responses to the open ended question about paying for health
care were very similar to responses to the questions regarding trade-offs
and recommendations. There are comments from a small number of individuals
who are strongly opposed to major changes to the current system or to
any changes that would increase the government’s role in health
care, but these were not the typical comments we received or what we
heard in meetings or from the Internet poll.

As illustrated in Figure 10, analysis of the comments shows that when
asked about what kinds of changes should be made to the way we currently
pay for care, most wrote about the need for a single health care system.
We know from the comments submitted as well as the discussions at the
meetings that the notion of a single health care system means a number
of different things to different people. For some, the most important
issue clearly was the need for a government-run program. For others,
it was an administratively simple program that would be available to
everyone but provided in the public and private arenas. Among the 2,511
respondents who wrote about the need for a single health care system
in response to an open-ended question about how health care should be
financed, 43 percent recommended a single-payer system, while 24 percent
discussed national health care and 18 percent discussed universal health
care. The remainder discussed the ideas of universal Medicare, universal
coverage, universal basic care, or universal access.

Figure 10:

Our current way of paying for health care includes payments
by individuals, employers, and government. Are there any changes you
think should be made to this system?

(Working Group Comments on Open-Ended Questions)

And, while a minority expressed the view that market reforms and advancements
in technology could help to control costs and lead to better access
to care, most of the people we heard from want more fundamental change.

The same notion—the need for a single national health care system—dominated
the responses to the final question that asked people for the single
most important recommendation for improving health care for all Americans.
See Figure 11.

Figure 11:

What is your single most important recommendation to make
to improve health care for all Americans?

(Working Group Comments on Open-Ended Questions)

There is a great deal of diversity in the ways people envision a reformed
system. They believe this can be accomplished, and most believe that
the resources are already there in our current system to achieve this
goal. A selection of sample comments is provided below.

The Working Group Heard Many Views about How to Make Health
Care Work for All Americans: Examples

"We need a single-payer system to control costs and promote
efficiency, and it has to be universal."

"I think the only thing that will work is creating a system
that includes everyone at a basic level of care with significant incentives
for preventive care. It could be done through a system of clinics located
near grocery stores (or WalMart-type stores), in schools and community
heath centers."

"Let's just do Medicare for everyone. And establish a universal
standard of electronic record keeping. Then everybody can go to the
doctor of their choice, when they need to, and nobody falls through
the cracks. And our health care system can focus on getting the right
treatment to people the best way, and the health care database can track
what treatments work best for whom, in the most cost effective way.
Until we have a system that guarantees universal, complete coverage,
we will never be able to track what basic, effective health care really
costs or establish mechanisms --or even rationing (which I don't think
we need)-- that does what is best for all;"

"Everyone pays a fair share, everyone has health care benefits."

"A non-profit single payer system that covered everyone would
be the best solution. This would save billions in the total cost of
health care in America. This plan could buy drugs with huge bulk discounts
like Medicare & congressional, & veterans plans do."

"Require all Americans to choose a health care option and
allow health care choices. Then let the free market reduce the costs.
The default option is a free Medicaid type program that only provides
emergency and preventative care."

"I believe if Americans see that financing is more fair (rich
paying more than the poor, the young contributing to the care of the
elderly, the healthy paying for the sick) and all according to their
level of income, this would be the first step in Americans accepting
financial trade-offs. If the financing is not transparent and fair,
there will be perpetual resistance. Second, I believe there must be
set up a public infrastructure for setting standards of coverage and
the availability of services that we are willing to fund. Such a public
commission would include both citizens and representatives of all health
care professions meeting apart from state or federal government. Such
commission governance should be on the state, not federal, level so
that local management is undergirding the system. Health resource management
is local. When American citizens see that a public entity is taking
the time and expertise to decide transparently what should and will
be covered according to some stated ethic and philosophy of health care
goals, trade-offs become more easily acceptable because the public is
involved (not private corporations or remote federal agencies making
such decisions). And finally, the public and local health care professionals
should have the right and access to express their opinions and desires
to such a public commission. There is a decision-making infrastructure
that carries real authority and control but that is also permeable and
open to citizen and professional input."

"All insurance should be tax deductible whether employer provided
or individually purchased, as well as health expenses should be deductible
below the 7.5 percent threshold. More transparency in both quality and
cost so that people can truly become health care consumers. Government
plans need to provide BASIC coverage and support care through community
health centers as most efficient way for free care to be administered."

"I believe people should have a choice in selecting and paying
for their healthcare. However, I believe the government should provide
catastrophic coverage for all people. It will pay for itself in reduced
neglect and dependency on government welfare and other programs."

"Put everyone in one risk pool and have a publicly financed,
privately delivered system instead of paying high administrative costs
for private insurance companies."

"Develop a coordinated system through the government that
assures access for all, including focusing on preventive care. Health
care should be regulated -- like utilities are regulated. The private
sector system is not working for the US. Every other developed country
has figured out a system; why can't we?"

"A single-payer system with a massive investment in information
technology that provides universal access to patients as well as providers."

"Enact a single payer system of national health insurance
with national standards and a global budget in which inequalities in
health care delivery would be monitored and reported by race, ethnicity,
income, and disability status at the state and community levels to identify
inefficiencies that could be reduced by incorporating non-discrimination
standards into the regulatory structure at the federal and state levels."

"We need to set up a system like Social Security, where all
working people pay into it, but all get equal coverage. We also need
to tax not-for-profit institutions and systems that are currently acting
very much like for-profit systems to cover insurance costs for the uninsured,
the elderly, and disabled. If these systems are competing with one another,
and they are, they must contribute to the community need through tax
dollars, since they are duplicating services and keep building facilities
that are not needed."

"Medicare and the VA are and have been working. They are cheaper
than other options already in place and are more efficient in administrative
costs than many other options."

"A non-mandatory, semi-private, semi-government run health
insurance/free (or at least affordable, possibly based on income levels)
health care program to everyone in the country. A health care program
completely run by the government wouldn't work, but neither would one
that was privately run - something comparable in theory to the FEHBP.
And it should be either free service (paid for by taxes) for the patron,
or be priced according to income and possibly 'risky' behaviors."

"In addition, we need a system where health care is provided
by those best able to do it most efficiently including the highest quality.
There is too much reliance on physician specialists and not enough on
family physicians and nurse practitioners, nurse-midwives, nurse anesthetists,
etc."

"I like the idea of the health savings accounts -- but the
people that need the help can't afford the cost of the high deductible
insurance, so how can they afford to put $2500 or so a year in the savings
portions? Paying medical expenses from an account that they manage,
might make people monitor their health care costs. I do believe that
people on SSI - Medicaid overuse the system. But -- how can they not.
They don't have any experience with the health care system, having put
off all but the most critical care all of their lives. They only know
the emergency room, because they have only sought medical care in extreme
emergency in the past. To make the health savings account work, I think
the government should put the $2500 into the health savings account,
for all individuals below a certain income level."

"Create a system that seamlessly covers individuals from birth
to death. Health care is about the individual, not whether they work,
or have a disability, or fall within a certain age range. We keep everything
in this country piecemeal and segregated by false categorization and
because of that ensure a fragmented system with lots of individuals
falling through the cracks. Get rid of the fractured system based on
the private market. It doesn't work. It is costly and creates too many
gaps in care."

"There needs to be some combination of these things to allow
coverage for all Americans. Maybe we could expand Medicare/Medicaid,
or allow people without coverage to enroll in the federal employees’
plan, with a premium based on a sliding fee scale, so all pay something."

Endnotes

1 The New York Times/CBS News Poll of 1,229 adults, conducted January
20-25, 2006.

7 USA Today/Kaiser Family Foundation/Harvard School of Public Health:
Health Care Costs Survey (August 2005) conducted by telephone by ICR/Harvard
University between April 25 and June 9, 2005, with 1,531 adults age
18 and over responding. See Chart 6: Trends in Ability to Pay for Health
Care. Additional survey sources include The Gallup Organization and
Pew Research Center.

8 The New York Times/CBS News Poll of 1,229 adults, conducted January
20-25, 2006.

9 The Pew Research Center for the People and The Press Poll of 1,405
U.S. adults from March 8-12, 2006. “March 2006 News Interest Index.”

10 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325
U.S. adults conducted by Harris Interactive between July 11 and 13,
2006. See the Wall Street Journal Online (July 31, 2006), “Higher
Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent
of U.S. Adults.”

11 Gallup Poll of national random sample of 1,010 U.S. adults age 18+,
conducted in September 2005. See The Gallup Poll (November 22, 2005),
“Healthcare Panel: More Information, Stat.”

12 Wall Street Journal Online/Harris Interactive Health-Care Poll of
2,267 U.S. adults conducted online by Harris Interactive between September
21 and 23, 2004. See The Wall Street Journal Online (October 1, 2004),
“Doctors’ Interpersonal Skills Valued More than Their Training
or Being Up-to-Date.”

13 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325
U.S. adults conducted by Harris Interactive between July 11 and 13,
2006. See The Wall Street Journal Online (July 31, 2006), “Higher
Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent
of U.S. Adults.”

14 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325
U.S. adults conducted by Harris Interactive between July 11 and 13,
2006. See The Wall Street Journal Online (July 31, 2006), “Higher
Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent
of U.S. Adults.”

15 Los Angeles Times/Bloomberg Press of 2,563 adults conducted by
Roper Center for Public Opinion Research between February 24 and March
5, 2006.

20 Wall Street Journal/Harris Interactive Health-Care Poll of 2,325
U.S. adults conducted by Harris Interactive between July 11 and 13,
2006. See The Wall Street Journal Online (July 31, 2006), “Higher
Premiums for Those with Unhealthy Lifestyles Supported by 53 Percent
of U.S. Adults.”

21 The Pew Research Center for the People and the Press (May 10, 2005)
“Beyond Red vs. Blue.” The 2005 Political Typology Survey
is a national telephone interview sample of 2,000 adults age 18 and
over. The Typology Callback Survey conducted in March 2005 obtained
1,090 respondents from the initial December 2004 survey. The national
sample of 1,284 adults in the 2003 survey was conducted by Princeton
Survey Research Associates between July 14 and August 3, 2003.